Osteoporosis is caused by estrogen deficiency after menopause. It leads to reduced bone density and increased fracture risk. Over 50% of postmenopausal women suffer osteoporotic fractures. Risk factors include advancing age, family history, smoking, excessive alcohol, low body weight and falls. Diagnosis involves testing for bone mineral density loss using DXA scanning or calculating fracture risk with FRAX. Prevention focuses on exercise, nutrition, fall prevention and medications. Cardiovascular disease risk rises after menopause due to declines in estrogen and HDL cholesterol and increases in blood pressure and LDL cholesterol. Risk is assessed through history, exams and testing to determine prevention strategies. While estrogen was thought to benefit brain function,

1. Long term complication of
menopause
Osteoporosis
Dementia
Cardiovascular disease
Medical student MBBS year 4 UniSZA –
Siti hamidah

2. OSTEOPOROSIS
• Mainly in postmenopausal
• Estrogen as antiresorptive agent on bone
• Estrogen deficiency  reduced bone density,
increased bone fragility  fracture risk
• 50% women suffer osteoporotic fracture
• Preventive measure of high risk
Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

3. Risk of osteoporotic fracture in
postmenopausal women
Non-modifiable
1. Advancing age
2. Ethnic group (Oriental &
Caucasian)
3. Female gender
4. Premature menopause (< 45
years) including surgical
menopause
5. Family history of osteoporotic
hip fracture in first degree
relative
6. Personal history of fracture as
an adult
Modifiable
Low calcium and/or vitamin D
intake
Sedentary lifestyle
Cigarette smoking.
Excessive alcohol intake (>3
units/day)
Excessive caffeine intake (>3
drinks/day)
Low body weight (BMI < 19kg/m2)
Estrogen deficiency
Impaired vision
Recurrent falls
Ministry of Health Malaysia (2012). Clinical Practice Guidelines:Osteoporosis. Malaysia

4. Presentation
asymptomatic and diagnosis is made only after a
fracture
Common:
1. Increasing dorsal kyphosis (Dowager’s hump)
2. trauma fracture
3. Loss of height
4. Back pain
Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

5. diagnosis
• made after excluding secondary causes
• history, physical examination
• laboratory investigations
gold standard  bone mineral density (BMD)
using dual energy x-ray absorptiometry (DXA).
If not available, calculating the risk of fractures
using Fracture Risk Assessment Tool (FRAX) can
help in deciding treatment strategies
Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

6. criteria
• individual's age (40-90 y) , sex, weight, height,
prior fracture, parental history of hip fracture,
• smoking, long-term use of glucocorticoids,
rheumatoid arthritis and alcohol
consumption.
Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

7. screening
• based on age and weight, Osteoporosis
• Self-Assessment Tool for Asians (OSTA), was
developed for postmenopausal Asian women.
Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

8. investigation
The main aims of investigations are to:
• 1. Confirm the diagnosis of osteoporosis
• 2. Assess fracture risk
• 3. Exclude secondary causes
Initial investigations include:
• 1. Full blood count and erythrocyte sedimentation rate
(ESR)
• 2. Bone profile: serum calcium, phosphate, albumin
• 3. Alkaline phosphatase
• 4. Renal function
• 5. Plain X-rays Ministry of Health Malaysia (2012). Clinical
Practice Guidelines:Osteoporosis. Malaysia

9. Prevention
• Exercise
• Nutrition: Calcium,protein and vit D
• Limit smoking,caffein
• Fall prevention (reduced muscle strength,Low vitamin D
levels,Poor vision,Hazards in the home (e.g. inadequate lighting,
slippery floors)
• Bisphosphonate (reduce bone absrption)
• Raloxifene (selective estrogen receptor modulator)
• Tibolone, selective tissue estrogenic activity regulator. Increases
lumbar spine BMD by 6.6% and hip BMD by 2.8% with decrease
in vertebral fractures by 45% and non-vertebral fractures by
26%.
• HRT
Ministry of Health Malaysia (2012). Clinical Practice Guidelines:Osteoporosis. Malaysia

10. Cardiovascular Diseases
• A decline in estrogen level may be a factor
because it believed to have positive effect on
the inner layer of arterial wall, help to keep it
flexible
• Associated with increase bp after menopause,
LDL cholestrol increase and HDL cholestrol
tend to decline
(American heart association)

11. Refresh…….
• Cardiovascular disease (CVD) includes:
1. Coronary heart disease (CHD) as manifested by angina
pectoris, MI, heart failure (HF) and coronary death
2. Cerebrovascular disease manifested as transient
ischaemic attack (TIA) and stroke
3. Peripheral arterial disease (PAD) manifested as
intermittent claudication and critical limb ischaemia
(CLI)
4. Aortic atherosclerosis and thoracic or abdominal
aortic aneurysm. Although these are manifestations
of atherosclerosis, in some clinical studies, they are
not included in the definition of CVD
CPG prevention cardiovascular disease in women 2008

12. CARDIOVASCULAR RISK FACTORS
a) Non-modifiable risk factors
1. personal history of CHD and/or CHD equivalents
2. age (over 55)
3. family history of premature CHD
b) Modifiable risk factors
1. dyslipidaemia
2. hypertension
3. diabetes mellitus/pre-diabetes
4. metabolic syndrome
5. obesity
6. smoking
7. physical inactivity
CPG prevention cardiovascular disease in women 2008

13. Assessment of CVD risk involves:
–– History: Looking for symptoms of CHD or CHD
Equivalents, family history of premature CHD,
smoking status, physical activity
–– Physical Examination: Height, weight, BMI,
waist circumference, pulses, blood pressure
–– Investigations: Blood sugar, lipid profile
CPG prevention cardiovascular disease in women 2008

14. TOTAL CARDIOVASCULAR RISK
ASSESSMENT
• Framingham Risk Score (FRS)
• SCORE system
• WHO/ISH Cardiovascular Risk Prediction
Charts
CPG prevention cardiovascular disease in women 2008

15. RECOMMENDATIONS FOR
PREVENTION OF CVD IN
WOMEN
• Lifestyles changes : dietary, exercise, weight
reduction, stop smoking
• aspirin
CPG prevention cardiovascular disease in women 2008

16. DEMENTIA
• Estrogen stimulates the brain’s neurotransmitter
that are responsible for memory and language
Healthline.com
• However the link between circulating estrogen
and cognitive impairment is weak
• Clinical trial of midlife hormone therapy have not
shown improved cognition
By the north american menapouse society : www.
Menapouse.org