By Siraya Kitiyodom

1. ปัญหาที่เกี่ยวกับสุขภาพที่พบบ่อยในสตรีวัยทองและวิธีการดูแล (Part II) By Siraya Kitiyodom

2. BONE By Siraya Kitiyodom

3. Management • Brain symptoms • Prevalence • Mood • Estrogen as an neuromodulator • Depression • Vasomotor symptom • Definition • Physiology • Management • Bone • Nonhormonal in menopause • Hormone replacement therapy

4. Scope • Definition • Pathogenesis • Evaluate & Diagnosis • Treatment

5. Definition • Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. • Bone strength primary reflects the integration of bone density and quality NIHConcensus Development Panel an Osteoporosis , 2001

6. Bone Strength Bone Density Bone Strength NIH Consensus Statement 2001 Bone Quality + Architecture and geometry Degree of mineralization Properties of collagen/mineral matrix Damage accumulation Turnover/ remodeling rate NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95

7. Scope • Definition • Pathogenesis • Evaluate & Diagnosis • Treatment

8. Bone Biology • TYPE OF BONE Bone can be divided into 2 major types • Cortical - Outer shell of all bones - 75% of total bone mass • Trabecular -Spongy, open architectural structure - Most of the volume in bone - 25% of total bone mass

9. Trabecular bone Larger surface area Higher turn over rate Show early bone loss First respond to therapy ACOG Practice Bulletin. 2004; NO. 50: 203-216

10. Cortical vsTrabecular

11. Bone Biology ACOG Practice Bulletin. 2004; NO. 50: 203-216 • Bone mass peaks at approximately age 30 years in both men and women • After reaching peak bone mass, approximately 0.4% of bone is lost per year in both sexes • Women lose approximately 2% of cortical bone and 5% of trabecular bone per year for the first 5–8 years after menopause

13. Bone cell Osteoblast Bone formation Osteoclast Bone resorption Osteoblast that trap in matrix Osteocyte

15. OSTEOPOROTIC FRACTURE Calcium deficiency Primary Vit D deficiency Primary 1.25-(OH)2D3 deficiency / resistance Parathyroid hyperplasia Hormone deficiency (estrogen, testosterone, 1.25 (OH)2D3, GH, IGF) Muscle strength  Sense of balance  Mental status  Reflexes  Mobility  Type I Type II Secondary hyperparathyroidism Low bone mass Bone strength Tendency to fall Fractures

16. Type II • Endocrine • Cushing • Thyroid/parathyroid • hypogonadism Drug -glucocorticoid -heparin, warfarin -phenytoin, phenobarb -CA drug Systemic disease -renal disease -liver disease -malabsorb -rheumatoid -CA

17. Scope • Definition • Pathogenesis • Evaluate & Diagnosis • Treatment

18. Risk factor • Non modification - Age > 65 - asian - early menopause (< 45 year) - small body built - Hx fragility fracture - Family Hx – osteoporosis/osteoporosis Fx • Modification - low intake calcium - sedentary lifestyle - smoking, alcohol, caffeine - BMI < 19kg/m2 - estrogen deficiency

19. Evaluate • Risk assessment of osteoporosis fracture (FRAX) • LAB • Bone strength assessment • Biochemical marker of bone turnover

20. FRAX

23. Evaluate • Risk assessment of osteoporosis fracture (FRAX) • LAB • Bone strength assessment • Biochemical marker of bone turnover

24. LAB • CBC • Calcium, phosphate, albumin • Liver function test • Renal function • X-ray – Lateral TL spine or AP hip (suspected fracture)

25. Evaluate • Risk assessment of osteoporosis fracture (FRAX) • LAB • Bone strength assessment • Biochemical marker of bone turnover

26. Bone strength assessment • Plain X-ray (BMD<30%) • Semi-quantitative method (high intra & inter observer) • Bone mass measurement -> axial dual energy X-ray absorptiometry (axial DXA)

27. Bone mass measurement • Indication - Age > 65 - Age < 65 - early menopause - estrogen deficiency > 1 yr - on glucocorticoid - BMI < 19 kg/m2 - parent hip Fx history - X-ray find osteopenia/vertebral fracture - fragility fracture - decrease height - screening -> high risk – OSTA score 0.2 X (BW – Age) > -1  low risk < -1 to > -4  moderate risk < -4  high risk

28. Bone mass measurement WHO Study Group. Osteoporos Int,1994;4:368-381.

29. Scope • Definition • Pathogenesis • Evaluate & Diagnosis • Treatment

30. Stategy NORMAL OSTEOPOROSIS FRACTURES MORTALITY & MORBIDITY “Surgery & Rehabilitation” “Prevention” “Treatment”

31. Prevention • Strategy to maximize peak bone mass • Strategy to prevent bone loss - weight bearing exercise - life style modification - nutrition – Calcium Daily intake of calcium. Women < 50 years : 1,000 mg Women > 50 years : > 1,200 mg In dietary  ~ 500-600 mg. calcium/day Calcium supplement Divided dose, with meal, and single dose< 1,000 mg – Vitamin D (800 iu) - prevent fall

32. Treatment • Indication - Primary indication - Menopause – Fragility fracture (vertebrae or hip) – BMD T score < -2.5

33. Treatment • Indication - Secondary indication - BMD – 2.5 < T score < -1 with - major fragility Fx e.g. ankle, wrist, pelvis - use glucocorticoid - secondary osteoporosis e.g. thyrotoxicosis - FRAX (no BMD) 10 yr probability of hip Fx > 3% other Fx > 20% - clinical risk factor - parent Hx hip Fx - Premature menopause - smoking / alcohol

34. DRUG • Hormonal • Bisphosphonate • Calcitonin • Parathyroid hormone • Strontium ranelate • Vitamin K2 • New drug

35. Effects of Medication on Bone Remodeling Inhibit bone resorption & Stimulate bone formation Strontium ranelate Vitamin k2 Stimulate bone formation PTH Inhibit bone resorption HRT Bisphosphonate SERM Calcitonin www.umich.edu/news/Release/2005/Feb05/bonehtml

36. DRUG • Hormonal • Bisphosphonate • Calcitonin • Parathyroid hormone • Strontium ranelate • Vitamin K2 • New drug

37. HRT • Estrogen therapy(ET) - prevention of bone loss and fractures in postmenopausal women with or without established osteoporosis - FDA approved only for the prevention of postmenopausal osteoporosis - reduce vertebral and non vertebral fracture - effect are exerted through estrogen receptors (present on monocyte lineage and osteoblasts) - anti bone resorption

38. THE END