COMMENTARY

Osteoporosis in Menopausal Women

Andrew M. Kaunitz, MD

Disclosures

February 29, 2016

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Hello. I'm Andrew Kaunitz, professor and associate chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville. Today, I'd like to discuss osteoporosis in menopausal women, prevention with hormone therapy (HT), and treatment with bisphosphonates.

One half of all women in the United States will experience an osteoporotic fracture, and as many as 1 in 5 will experience hip fracture.[1] The good news is that our understanding of prevention of osteoporosis, as well as treatment aimed at prevention of fractures, has advanced substantially in recent years.

Since the 2002 publication of initial findings from the Women's Health Initiative, safety concerns have led to dramatic reductions in the use of systemic HT.[2] Amidst these safety concerns, the important role that HT can play in preventing osteoporosis has been downplayed.

I counsel my menopausal patients who are considering starting or continuing HT about the clear evidence that HT prevents osteoporosis, and that such prevention is listed as an indication in package labeling. HT's role in preventing loss of bone mass is particularly important for women at higher risk, including those with a low body mass index, smokers, those with a parental hip fracture, corticosteroid users, and those with inflammatory bowel disease or rheumatoid arthritis.

In women who have outgrown their vasomotor symptoms, very low doses of estrogen prevents loss of bone mass. The ultra–low-dose 0.14-mg estradiol skin patch has been found to prevent loss of bone mass and can be used without progestational endometrial protection.[3]

Let's move on from the prevention of osteoporosis to the treatment of this condition. Conventional wisdom has suggested that exercise plays a key role in preventing fractures. Unfortunately, available evidence does not confirm that weight-bearing activities prevent fractures. Having said that, regular exercise does prevent cardiovascular disease and plays an important role in maintaining an appropriate weight. Furthermore, exercise can improve balance, thereby reducing the risk for falls in older individuals.[1]

Pharmacologic treatment is indicated to reduce fracture risk in women with a history of a frailty fracture, when dual energy x-ray absorptiometry reveals T-scores < -2.5, or when loss of bone mass is associated with an elevated 10-year fracture risk using the FRAX online risk calculator.[4]

Oral bisphosphonates, which are available as generics, represent first-line therapy to prevent fractures in women who are at elevated risk. However, the use of bisphosphonates has been associated with safety concerns, particularly two rare complications: atypical subtrochanteric fractures and osteonecrosis of the jaw (ONJ). Publicity regarding these adverse events is now preventing many women who would benefit from bisphosphonates from using this class of medications.

A recent review that was published in the New England Journal of Medicine clarified that bisphosphonates should be considered safe and effective in appropriate candidates.[1] The review referenced a study that estimated that with treatment for up to 5 years in women with osteoporosis, 100 frailty fractures are prevented for each case of atypical fracture or ONJ.

As the authors pointed out, problems with oral bisphosphonates can be minimized with the following measures:

  • Adherence to dosing instructions to minimize gastrointestinal irritation;

  • Avoidance of bisphosphonates in women with clinically significant esophageal disease, a creatinine clearance < 35 mL/min, or low levels of 25-hydroxyvitamin D; and

  • Temporary drug holidays after 5 years of bisphosphonate use, to minimize the risk for atypical fractures or ONJ. Treatment should be reinstated within 5 years of stopping. This recommendation does not pertain to women who are at very high risk for future fractures on the basis of clinical history or very low T-scores. Such patients should continue bisphosphonates without a break.[1]

Thank you. I'm Andrew Kaunitz.

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