Postmenopausal Osteoporosis in the Primary Care Setting

1. Osteoporosis
&
Menopause
DR. KAWITA BAPAT

3. Postmenopausal Osteoporosis in the
Primary Care Setting
What is osteoporosis?
Why should you care?
Whom to test and how?
Whom to treat and how?

4. Definition of Osteoporosis
A skeletal disorder
characterized by
• Compromised bone
strength predisposing to
• An increased risk of fracture
Bone strength reflects
the integration of two
main features:
• Bone density
• Bone quality

5. Common risk factors for osteoporosis
• Female
• Postmenopausal
• Family history of osteoporosis
• Lack of exercise
• Small body frame

6. Common risk factors for osteoporosis
• Low calcium intake
• Vitamin D deficiency
• Smoking
• Age (starting in the mid-30s but more likely with advancing age)
• Rheumatoid arthritis, hyperthyroidism, hyperparathyroidism,
hypogonadism
• Medications – corticosteroids (Prednisone), excess thyroid hormone, some
diuretics (Lasix), and anticonvulsants (Dilantin, Phenobarb, Tegretol)

7. Osteoporosis in Perspective
Lifetime risk at age 50
50%
12%
Women
Fracture Breast Cancer
20%
17%
Men
Fracture Prostate Cancer

8. National Osteoporosis Foundation: 2013
Guidelines
Universal
(risk, diet, vitamin D,
exercise, smoking,
monitoring)
Diagnosis
(BMD, vertebral imaging,
causes of secondary
osteoporosis)
Monitoring
(BMD)
Treatment
(initiation criteria,
options, duration)
Major clinical recommendations

9. Women aged 65 and older and
men aged 70 and older
Younger postmenopausal women and men
ages 50–69 with clinical risk factors
Adults with a condition (e.g., rheumatoid arthritis)
or taking a medication (e.g., glucocorticoids)
associated with low bone mass or bone loss
Adults who have a fracture after age 50

10. WHO Criteria for
Postmenopausal Osteoporosis
• The T-score compares an individual’s BMD with the
mean value for young adults
• Expresses the difference as a standard deviation score.
Category T-score
Normal -1.0 and above
Low bone mass (osteopenia) Between -1.0 to -2.5
Osteoporosis -2.5 and below

11. Whom to Treat: NOF Guidelines 2013
Women ≥ 65 and men ≥ 70
(younger with risk factors)
T-score ≤ -2.5 in the lumbar spine,
total hip, or femoral neck or
Hip or spine fracture (clinical or radiographic)
T-score between -1.0 and -2.5
and increased fracture risk
DXA test
Candidate for
TREATMENT
YES
YES
≥ 3% for hip fracture
or
≥ 20% for major osteoporotic fractures
FRAX
10-y fracture risk

13. Clinical Benefits of FRAX
Derives 10-year probability of clinical event
from measurable parameters
Internationally recognized and validated
Based on data from multiple cohorts
Easily accessible on the Internet or DXA software
Helps identify patients who need treatment

14. Limitations of FRAX
Not valid to monitor patients on treatment
Only femoral neck BMD is considered
Risk is “yes/no” – there is no consideration of “dose”
(e.g., fractures, glucocorticoids, smoking, alcohol)
Not all risk factors are included
Clinical judgment is required
Do patients with high FRAX scores benefit from medication? (Unknown)

15. What Is The Role of The Gynecologist ?
At Adolescent & Adult Age
To achieve a peak bone mass
At Peri-menopause
To prevent osteoporosis in high-risk group
Treat postmenopausal osteoporosis
At Late Post-menopause?
To prevent age related osteoporosis (>65y)
Usually, it is an orthopedic role

16. Levels Of Management
PRIMARY PREVENTION: Preconception, in utero, childhood
nutrition to attain highest “ peak bone mass”, avoid risk factors —
Children, Adolescents and Adults
SECONDARY PREVENTION: Prevent first fracture after osteoporosis
has set in
TERTIARY PREVENTION: After first osteoporotic fracture has
occurred prevent another

17. Indian Scenario: Prevalence of low bone mass
• 40 yrs >40%
• 60 yrs >62%
• 65yrs >80%
Occurs 10 yrs earlier
High Prevalence OF Post Menopausal Osteoporosis in Indian women
• Calcium intake-<400mg/day-ICMR STUDY
• Low Vit D -health professionals-80%
• Low Protein
• Sedentary lifestyle
• Early age of menopause
Attention needed: To tackle the modifiable factors

18. The Recommended Dietary Allowance (RDA) of calcium intake
for Adult Indian
Group Calcium (mg)
Adult Women 600
Pregnancy 1200
Lactation 1200
Post-menopausal women 800

19. DIETARY PRODUCT SERVING CALCIUM (MG)
Vegetables
Okra(Bhindi) 100 gms 85
Drum stick leaves 100 gms 300
Radish and methi leaves 100 gms 270
Mint /Parsley/Coriander leaves 100gms 200
Broccoli 100 gms 118
Cabbage 100 gms 60
Sarson 25 gms 155
Spinach 100 gms 130
Nuts/seeds
Til seeds 10 gms 1 tablespoon
90
Almonds 1 handful, 25 60
Cumin 6 gms, 1 tablespoon 60
Fruits/Fish
Orange medium size
50
Rahu 25gms 160
Calcium Rich Diet

20. Calcium Absorption Efficiency from Various Salts at Loads of 200-300 mg in
Premenopausal women

21. Guidelines from India
• Total calcium intake from dietary sources and if needed, supplements are
used to correct the deficient balance. The intake should exceed >800 mg/day
(Grade B).
• The risk of cardiovascular events, calculi are not observed with the
recommended doses of calcium.
Indian Menopause Society Guidelines-2020
• Consume 500–600 mL of milk or curds (low fat) to build on calcium bank in
bones
• Support it with lots of vitamin C-rich fruits/vegetables to favor calcium
absorption
• Protein should be 1gm/Kg body weight
• Avoid more than 200 mg/day of caffeine
• Daily salt intake should not exceed 5gm (1 tsp)
• Limit alcohol and avoid tobacco

22. Vitamin D
deficiency
Reduced active
calcium absorption
Affects bone
metabolism
Increased PTH
secretion
Induce 1α-
hydroxylase
activity in kidney
Converts vitamin D
to calcitriol that
enhances calcium
absorption from gut
Vitamin D
Two forms:
• Vitamin D2 - Ergocalciferol
• Vitamin D3 – Cholecalciferol
In humans, both cholecalciferol and ergocalciferol are sequentially transformed into 25-
hydroxyvitamin D3, 25-hydroxycholecalciferol or calcitriol, in the liver

23. Life Stage group Daily Requirement UL
Infants (0-12 Months) 400 –1000 IU 2000
Adults (1-18 year) 600-1000 IU 4000 IU
Age (19-50 year) 1500-2000 IU 10,000 IU
Age (50 & Above) 1500-2000 IU 10,000 IU
Pregnancy & Lactation (14-18 yr) 600-1000 IU 4000 IU
Pregnancy & Lactation (19-50 yr) 1500 – 2000 IU 10,000 IU
Recommendation: RDA Vitamin D
Guidelines on Management Of Menopause 2019
Indian Menopause Society

24. Vitamin D necessary for Calcium Absorption
• Choose a supplement with vitamin D unless obtaining vitamin D from
other sources.
• Follow age group recommendation.
• Avoid going over a daily combined total of 2,000 IU or 50 mcg from
food and supplements.
• It’s not necessary to consume calcium and vitamin D at the same time
to get the benefit of enhanced calcium absorption.
Management & Maintenance
of Vit D Deficiency
• Adequate sunlight exposure
• For deficiency: Cholecalciferol( Vit D 3) tablet or powder 60,000
IU/once a week for eight weeks preferably with milk
• Maintenance therapy: Cholecalciferol tablet or powder 60,000 IU once
or twice a month

25. Lifestyle Changes To Improve Bone Health
Exercises: Resistance, balance, and weight-bearing
Safe movements: Avoid Falling
Balanced diet: calcium & Vit-D rich foods
Sunshine
Prevent obesity
Avoid smoking
Limit alcohol consumption

26. Exercise Prescription
• Exercise should include aerobic, muscle
strengthening, breathing and balance
• 30 minutes of moderate-intensity physical activity
mostly 5 days a week
• Muscle-strengthening activities should be included
at least 2 days/week
• 30 minutes/day – For fitness and reduced risk of
chronic disease
• 60 minutes/day – For prevention of weight gain
• 60–90 minutes/day – To avoid regain of weight loss
AVOID:
• Spinal flexion (forward or side)
• Spine hyperextension
• Spinal loading (jumping motions)

27. Osteoporosis
Post-
menopausal
Glucocorticoid
-induced Male
Drug Prevent Treat Prevent Treat
Estrogen 
Calcitonin* (Miacalcin®, Fortical®) 
Raloxifene (Evista®)  
Ibandronate (Boniva®)  
Alendronate (Fosamax®)    
Risedronate (Actonel®, Atelvia®)     
Risedronate (Atelvia®) 
Zoledronate (Reclast®)     
Denosumab (Prolia™)  
Teriparatide (Forteo®)   
FDA-approved Medications

28. Estrogen effects on
osteocytes/osteoclasts/osteoblasts
Regulator of bone
growth
Regulation of
bone remodeling
Decrease bone
resorption
Maintenance of
bone formation
Regulation of
osteoclasts

29. Decreased ovarian function and reduced estrogen production
are associated with loss of bone mineral density
Bone
density
Men
Women Peak
bone
density
Menopause
transition
Risk of
osteopenia/osteoporosis
10 20 30 40 50 60 70 80
Age
(years)
Beginning from the
menopause
transition, reduced
estrogen
leads to a decrease
in critical
bone mass

30. International Menopause Society Recommendations –
2016
An appropriate assessment of prevalent fractures and secondary causes of
osteoporosis should precede any therapeutic decisions
Lifestyle strategies should be part of any treatment strategy [A]
Choice of pharmacological therapy should be based on a balance of
effectiveness, risk and cost
MHT is the most appropriate therapy for fracture prevention in early
menopause

31. Role of MHT in postmenopausal osteoporosis
AACE
Guidelines
2020
MHT is effective for prevention of
postmenopausal osteoporosis
When prescribing solely for the prevention
of postmenopausal osteoporosis, therapy
should only be considered for women at
significant risk
Women at significant
risk of osteoporosis
When non-estrogen
medications are not
considered to be
appropriate

34. Role of MHT in postmenopausal osteoporosis
Endocrine Society
Guidelines 2019
MHT to be used for prevention
of all types fractures in
postmenopausal women at
high risk of fracture and
following characteristics,
Under 60 years of age
or < 10 years past
menopause;
those in whom
bisphosphonates or
denosumab are not
appropriate;
with bothersome
vasomotor symptoms;
without
contraindications;

35. Use of MHT only to symptomatic women then what is the
“Window of Opportunity”?.....Osteoporosis!!!
VMS and Osteoporosis:
Any Correlation??
• Yes
moderate/severe VMS
• lower BMD at the
femoral neck and lumbar
spine and increased
rates of hip fractures
Osteoporosis related
Morbidity-Mortality can be
reduced if MHT is initiated
for symptomatic women
• Before the age of 60
years or within 10 years
after menopause.
Window of Opportunity
Initiation after the
age of 60 years
requires
individualized
approach

36. Pragmatic approach
MHT
Can be Considered
Osteopenia, not meeting
therapeutic threshold for
osteotropic drugs;
Intolerance to drugs
Osteoporosis
Refractory
Osteoporosis/
Atypical
Fractures

37. Benefits: sequential combined MHT may reduce loss of
bone mass density
References
37
5.16
2.67
6.71
2.52
-1.59 -1.81
-10
-6
-2
2
6
10
14
Lumbar spine
(N = 368)
Femoral neck
(N = 367)
*
*
*
*
Mean
change
from
baseline
in
BMD,
±SD
(%)
1 mg E2 + D (5 mg or 10 mg)
2 mg E2 + D (10 mg or 20 mg)
Placebo
Sequential E/D effective versus placebo in preventing loss
of
bone mass in the lumbar spine and femoral neck over 2
years (n = 595)

38. Individualizing MHT
<40
Years
40-
50
Years
50-60
Years
>60
Years
Premature Ovarian Insufficiency (POI)
MHT is Mandatory* till Natural Age of
Menopause
Benefits Exceed Risk
Benefits Exceed Risk
(if <10 Years of Menopause)
Risk can be More
(Need to evaluate)

39. Baseline Investigations
CBC
Blood Glucose
(Fasting/PP),
HbA1c
TSH
Lipid Profile
Vit-D Levels
(if at increase risk)
Renal & Liver
Function Test
Cervical Smear
HPV Screening
Transvaginal
Ultrasound
Mammography

40. Effective Counselling of the Women
Objectives
To address Concerns
and Questions on
Menopause & MHT
To educate the women
To enhance the
confidence and
facilitate decision
making
Important
Components
Meaningful
relationship
Clear
Communication
Informed Decision
Making
Risk Explained in
Absolute Numbers
(Instead of
Relative Risk)
Evaluating
Understanding of
Woman
Respecting Her
Preferences

41. Benefits of HRT
1) Gupta A, Tiwari P, Khare C. Premature Ovarian Insufficiency: A Review. EMJ Repro Health. 2019. 2) Goswami D. Primary
Ovarian Insufficiency: The Paradox of Menopause in Young Women. MAMC J Med Sci 2015;1:3-5.
OVERCOMES ESTROGEN DEFICIENCY
Improves lipid profile by increasing serum high-density lipoprotein and decreasing total
cholesterol and low-density lipoprotein
Reduces the risk of coronary artery disease by 24%
Improves BMD and significantly reduces risk of fracture
Reverses the urogenital atrophy caused by oestrogen deprivation and relieves vasomotor
symptoms
Improves the overall quality of life