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About Osteoporosis
Author:
J. S. Dexeus
gynaecologist
Last Review: 21/02/2003
Osteoporosis is a preventable condition. Although it is responsible
for much morbidity and even death, primary osteoporosis is not
a disease in the true sense of the word. For this reason, it
is realistic to anticipate that in the next century, we will
regard osteoporosis in a historical context, much as rickets
and vitamin D deficiency are regarded today. Achievement of
this goal will, however, depend on two factors:
- Educating
the lay community about the importance of developing maximal
bone mass before menopause;
- Introducing
into the health-care system easily accessible and reimbursable
means of identifying women at risk for osteoporosis.
Accomplishing
these tasks will make effective preventive care possible.
Osteoporosis is a skeletal disease characterized by low bone
mass and microarchitectural deterioration of bone tissue,
leading to enhanced bone fragility and a consequent increase
in fracture risk. Three main factors are responsible for the
fragility of bone:
- Reduced
bone mass;
- Impaired
repair of the microdamage caused by normal wear and tear
of bone, with disruption in continuity of the plates in
cancellous (trabecular) bone;
- Falls.
Because
disruption of the microanatomy of bone cannot be detected clinically,
the diagnosis and management of osteoporosis rests primarily
on the recognition of reduced bone mass. In this context, it
is important to draw a clear distinction between the following:
- Osteopenia:
Reduced bone mass due to inadequate osteoid synthesis; carries
no implication about causality;
- Osteoporosis:
A skeletal disease characterized by low bone mass and microarchitectural
deterioration of bone tissue, leading to enhanced bone fragility
and a consequent increase in fracture risk.
Osteopenia
is a risk factor; osteoporosis is the disorder. Osteoporosis
has a much higher incidence in women than in men, and occurs
primarily after the menopause. It is also more common in Caucasian
than in Black women.
Bone mass is believed to account for 75% to 85% of bone strength.
The primary goal is to recognize low bone mass (osteopenia)
early, with the objective of achieving a high peak bone mass
prior to the natural menopause and the subsequent age-related
years of bone mineral loss. At present, the tendency is to look
for and manage osteoporosis in postmenopausal and older women.
However, the path to osteoporosis begins with the first menstrual
period, a point that all women - and their physicians - should
be made aware of risk factors.
Since osteopenia can lead to osteoporosis in postmenopausal
period, the following steps can help prevent postmenopausal
osteoporosis:
- In
Premenopause: woman have to achieve the maximum bone mass
(Primary prevention);
- In
Perimenopause: woman have to schedule the Screen for osteopenia;
- In
Postmenopause: woman have to follow-up and counteract bone
mineral loss.
Osteoporosis
is a social phenomenon since involve about 15 to 20 million
women only in the United States. In addition, osteoporosis-related
hip fractures alone add a very high cost to health-care service
in the United States. The cost for spine and other regional
fractures is not known. Clinicians treat individuals; no price
can be put on the physical and psychological long-term consequences
of vertebral deformity and chronic back pain experienced by
an otherwise healthy woman. From this point of view, the prevention
could became an helpful instrument for Health Policy, also in
term of cost lowering.
Because of advances in technology and in our understanding of
the pathogenesis and treatment of osteoporosis, we now recognize
that it is never too:
- Early
to start prevention (the microarchitectural structure of
bone can not be restored, regardless an increase in BMD);
- Late
to treat established osteopenia and osteoporosis (recently
published papers seem to demonstrate the effectiveness of
HRT on osteoporosis, also in the late menopause and in established
osteoporosis).
Despite
arguments to the contrary, selective screening of asymptomatic
perimenopausal women to detect low bone mass is a cost-effective
use of health-care resources. In this way the new diagnostic
tools like the Ultrasound densitometry, less expensive and more
easy to use than the X-ray densitometry may represent a new
deal in the early diagnosis of bone loss. Certainly, the primary
prevention for osteoporosis at an early age, much can be done
to enhance bone density through:
- An
appropriate physical exercise;
- Good
nutrition (choosing calcium containing food);
- A
healthy lifestyle (avoiding smoke, alcohol, sedentary lifestyle,
etc...);
- The
selective use of anti-resorptive therapy (hormone therapy,
SERMs, isphosphonate, Calcium/ Vit. D supplemantation, etc...).
Primary-care
physicians and gynecologists, in particular, play a pivotal
role in preventing this condition. Thus, it's of paramount importance
to improve the prevention of this pathologic condition in term
of Health Care Service cost, and postmenopausal women health
care.
Bone remodelling activityThe bone is a very active tissue in
which a continuous turnover take place. The activity of the
bone remodeling cycle varies for each envelope depending on
age and reproductive status, as follows:
Bone Metabolic Activity at Different Age
|
Childhood: |
New bone formation on the periosteum exceeds endosteal
bone breakdown. A net increase in the outer diameter
of bone results. |
|
Adolescence: |
Bone formation occurs on both the endosteal and periosteal
surfaces with an increase in total bone mass. |
|
Early adulthood: |
Endosteal bone loss increases and begins to exceed periosteal
bone apposition, indicating the beginning of age/menopause-related
decrease in bone mass, with a resulting narrowing of
the intracortical envelope. The marrow cavity expands. |
References
- Cummings
SR, Black DM, Rubin SM. Lifetime risks of hip, Colles',
or vertebral fracture and coronary heart disease among white
postmenopausal women. Arch Intern Med. 1989;149:2445-2448.
- Dempster
DW, Lindsay R. Pathogenesis of osteoporosis. Lancet. 1993;341:797-801.
- Kanis
JA. Osteoporosis and osteopenia. J Bone Miner Res. 1990;5:209-211.
- Notelovitz
M. Osteoporosis: screening, prevention and management. Fertil
Steril. 1993;59:707-725.
- Riggs
BL, Melton LJ III. Involutional osteoporosis. N Engl J Med.
1986;314:1676-1686.
- Tosteson
AN, Rosenthal DI, Melton LJ III, Weinstein MC. Cost effectiveness
for screening perimenopausal white women for osteoporosis:
bone densitometry and hormone replacement therapy. Ann Intern
Med. 1990;113:594-603.
- Ettinger
B, Black DM, Mitlak BH, Knickerbocker RK, et al. Reduction
of vertebral fracture risk in postmenopausal women with
osteoporosis treated with raloxifene: results from a 3-year
randomized clinical trial. Multiple Outcomes of Raloxifene
Evaluation (MORE) Investigators. JAMA 1999 Aug 18;282(7):637-45.
Osteoporosis
Author:
J. S. Dexeus
gynaecologist
Last Review: 21/02/2003
Causes Osteoporosis is probably the metabolic disorder
that is most commonly found in the bones. It is understood as
a reduction in bone mass (B.M.). Normally the B.M. changes regarding
age, race and sex. Osteoporosis must not be confused with osteopenia,
which is an age-related loss of a certain amount of bone.
Whatever the age, osseous mineral density is the result of two
variables: the quantity of bone attained during growth (maximum
bone mass) and the subsequent rhythm of bone loss.
Bone loss in post-menopausal women is due to an imbalance between
bone resorption, which is increased, and bone formation, which
is reduced.
Consequences It is characterized by a greater risk of suffering
fractures when performing everyday movements and minimal traumatisms.
The most characteristic fractures are:
- Vertebral.
- Proximal
of the femur.
- 1/3
distal radius (Colles) ribs, humerus and pelvis.
However,
post-menopausal osteoporosis is not a uniform illness and is
more prevalent in some countries than in others, and affects
some groups more than others, depending on the risk factors
and/or predetermining factors.
The most important and decisive risk factor in the pathogeny
of post-menopausal osteoporosis concerns the estrogens.
Treatment The ideal treatment prevents or delays progressive
bone loss with age and avoids the appearance of fractures.
Treatment is based on: 1. General and prophylactic
measures
These measures must begin as soon as possible, even in adolescence.
Correct diet
- Calcium:
The calcium intake in childhood and adolescence is one of
the most important factors, which determines both the amount
of bone mass and the susceptibility to fractures in later
years. The recommended daily ration of calcium is around
1,000 mg/day for peri-menopausal women and 1,500 mg/day
for post-menopausal women.
When calcium is taken with food its absorption is 20 to
25% greater than when it is taken on an empty stomach. It
is best to divide the chosen daily dose into four separate
administrations. It is also advisable to give preference
to the night-time administration before sleeping.
A normal diet without lactic products contains some 300
mg of calcium, whereas a glass of milk contains 240 mg and
150 g of soft cheese contains 600 mg.
In addition to milk and its derivatives, calcium is contained
in:
broccoli, beans, sardines, almonds, vegetables and walnuts.
- Vitamin
C:
It is similarly important to attain a sufficient allowance
of vitamin C and manganese.
- Fluoride:
The needs of water with fluoride are 1 or 2 liters per week.
This water normally contains sodium, and it is therefore
contraindicated in cases of high blood pressure.
- Carbohydrates,
fats and phosphates:
High intakes of carbohydrates, fats and phosphates must
be reduced.
- Coffee,
fizzy drinks and proteins:
It is also important to reduce the intake of coffee and
fizzy drinks, as well as foodstuffs rich in proteins
- Alcohol:
Alcohol must be forbidden if the triglyceride level is high.
Hygiene Good
hygienic practice leads to an improved quality of life, not
only through its effects on osteoporosis but also through its
benefits on the lipid mechanism of carbohydrates and its effects
on obesity and high blood pressure.
- Sunbathing:
This increases the synthesis of vitamin D, thereby preventing
and treating osteoporosis. However, it should be born in
mind that excessive exposure to sunlight increases the risk
of skin cancer.
- Giving
up smoking:
Smoking contributes to the loss of bone mass. There are
studies showing that smokers reach menopause 1 or 2 years
sooner than non-smokers.
Exercise Lack
of physical activity increases resorption and reduces bone
formation.
Many studies have shown that exercise programs, generally
lasting several months, increases mineral bone density in
post-menopausal women.
Exercise must always be performed in accordance with the patient's
age, overall physical condition.
The duration of muscular activities like standing upright
can be more important than the strength or vigor with which
such an activity is carried out.
Young women as peri- and post-menopausal women with no fracture
risk can perform any type of physical activity.
For women with a risk of fractures, the following activities
are recommended:
- Walking:
At a higher speed than strolling (minimum 30 min/day).
- Swimming:
This exercises the back muscles and the upper and lower
limbs (any style can be used).
Overexercise must be avoided.
- Cycling:
A physiotherapist should give some preliminary posture.
This includes the height of the seat and the selection of
resistance and speed. The pulse must also be monitored to
avoid any overexertion.
- Specific
exercises for the back: These muscles are directly attached
to the vertebrae, which means that their contractions will
stimulate bone formation and reduce resorption. These exercises
have to be dynamic and repetitive.
- Forbidden
exercises: Neither aerobic exercise, nor any exercise involving
jumping, twisting or flexion of the back will be allowed
for women with a high risk of fractures. Such women will
be issued with a series of basic rules, such as:
- Avoid
any abrupt movements.
- Do
not lift any heavy weights.
They
will be taught how to:
- Bend
down correctly.
- Get
out of bed.
- Sit
down.
- Avoid
falls.
Some
studies have demonstrated that women who do exercise reduce
their number of hot flushes, improve their state of mind, avoid
overweight, reduce their cholesterol level and thereby enhance
the functioning of other organs (circulation, liver, etc.).
It is now well known that exercise induces a state of well being
and can produce a reduction in the symptoms of depression, anxiety
and insomnia.
2. Pharmacological treatment
The ideal treatment to avoid any loss of bone mass, and to recover
any already lost, would be one that inhibited resumption and,
at the same time, stimulated bone formation.
Substitutive hormonal treatment (see separate chapter)
Non substitutive hormonal treatment:
- Calcitonin:
This is a hormone secreted by the thyroid.
Calcitonin is useful to slow down bone loss in the
post-menopause period and thereby preventing fractures.
- Diphosphonates
or biphosphonates: They inhibit osseous resorption and mineralisation.
- Parathormone
(PTH): PTH stimulates the proliferation of bone cells in
cultures of tissue. It can increase the B.M. at small doses
- Fluoride:
Fluoride has a direct stimulating effect on the osteoblasts
and, through mitogenic action, on their precursor cells.
Calcium must be given at a dose of 1 g/day, although it
must not be taken simultaneously with Fluoride.
- Anabolizants:
Anabolizant steroids are androgens, which have been modified
in order to minimize their androgenic effects. Anabolizants
act as positive bone formers in the treatment of post-menopausal
osteoporosis.
We consider that, practically speaking, there are currently
no indications for anabolizants, if we take into account
their potential risks and the fact that they have no advantages
over the other drugs.
- Thiazides:
These are diuretics, which act by reducing the calcium urinary
excretion index, but the effect is temporary and only lasts
for a few months.
It would be possible to consider thiazides as a good alternative
for women who need diuretics.
WOULD
YOU LIKE TO KNOW MORE ABOUT THE FOLLOWING SUBJECTS?
3. Risk factors
Risk
factors for osteoporosis
- Female
sex.
- Caucasian
or Asiatic race.
- Family
history of osteoporosis
- Fair
skin.
- Small
osseous frame.
- Reduced
calcium intake.
- Early
menopause or surgical castration.
- Prolonged
amenorrheic episodes (particularly during growing up, nervous
anorexia).
- Sedentary
lifestyle.
- Nuliparity.
- Increased
sodium intake.
- Smoking.
- High
caffeine intake.
- High
protein intake.
- Factors
causing bone loss (steroids, hyperthyroidism).
- From:
"Osteoporosis: a guide to prevention and treatment", pages
27-28. John F. Aloia (Ed.), Leisure Press, Champaign, Illinois
(1989).
4.
Bones and alcohol
Alcohol reduces the bone mass by interfering with the calcium-phosphorus
metabolism, and it produces corticoid hypersecretion, poor absorption
and metabolic acidosis, as well as alterations in the hepatic
metabolism of vitamin D3.
5. Sun and D-vitamin
This increases the synthesis of vitamin D, thereby preventing
and treating osteoporosis.
Fifteen minutes of exposure to the sun is required for the reaction
to saturate so that the ultraviolet light transforms the 7-dehydro
cholesterol into vitamin D.
However, the radiation needed to produce a specific amount of
vitamin D is at least three times higher in elderly people than
in young adults. This is because there is a reduction in the
skin's capacity to synthesize vitamin D.
It should be borne in mind that excessive exposure to sunlight
increases the risk of skin cancer.
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