Management/Prevention of Menopausal Complications

1. Management/Prevention of Menopausal Complications

2. Postmenopause • Issues for primary care physicians and gynecologists: • Hormonal changes • Cardiovascular disease • Osteoporosis • Post menopausal bleeding (PMB) • Abnormal PAP’s • Sexual Function • Depression • Cancer screening and prevention • Lifestyle and habits

3. Causes of Mortality Men and Women • Cardiovascular Disease 2199.9/100,000 • Heart disease 1772.2/100,000 • Cerebrovascular diseases 427.7/100,000 • Malignant Neoplasms (all) 1316.6/100,000 • Influenza and pneumonia 166.4/100,000

4. Postmenopause • Cardiovascular Disease • Leading cause of death in men and women • Due to lack of protective effect of estrogen • Preventive measures • Exercise • Diet • Quit smoking • Moderate alcohol intake • Low dose aspirin ??

5. Postmenopause • Hot flushs • Very disturbing • Every few min to hours. Mostly first year • Less in obese women • treatment • HRT • Tibolone • SSRIs may reduce by 60% • Gabapentine (neurontoin) • Clonidine (captopril)

6. Osteoporosis

7. Osteopenia- reduction in bone mass below the theoretical fracture threshold. Osteoporosis- reduction in the bone mass to a level where there is increased risk of fracture in the absence of trauma. Or a fracture has already occurred. Clinical Definitions

9. Typical comments from people with osteoporosis “I’ve lost six inches in height and none of my clothes fit me anymore. Plus, it’s hard to get clothes that look nice when my back is so hunched over.”

10. Overview Osteoporosis causes weak bones. In this common disease, bones lose minerals like calcium. They become fragile and break easily. Normal Bone Bone with Osteoporosis

11. A woman’s hip fracture risk equals her combined risk of breast, uterine and ovarian cancer.

12. The most common breaks in weak bones are in the wrist, spine and hip.

13. Osteoporotic fracture Osteoporotic bone

14. Classification: • Primary • Type 1- post menopausal • Type 2- senile • Secondary • Medications • Steroid induced • Medical conditions • Spinal cord injury

15. Type 1 (postmenopausal) • Women > Men (6:1 ratio) • Related to estrogen • Affects trabecular bone • Associated with vertebral fractures • Unrelated to calcium intake • High bone turnover Vertebral compression fractures

16. Type 2 (Senile Osteoporosis) • Elderly Age >75yrs • Women:Men 2:1 • Calcium deficiency is major factor • Affects trabecular and cortical bone • Vertebral compression, hip, and distal radius fxs. • Slow bone turnover

17. Common Locations of Osteoporotic Fractures in General Population • Thoracic (vertebral) compression fractures • Hip fractures • Wrist/extremity fractures.

18. Endocrine and metabolic*Hypogonadism*Hyperadrenocorticism*Thyrotoxicosis*Anorexia nervosa*Hyperprolactinemia*Porphyria*Hypophosphatasia*Type 1 diabetes*Pregnancy*Hyperparathyroidism*Acromegaly Disorders of collagen metabolism*Osteogenesis imperfecta*Homocystinuria*Ehlers-Danlos syndrome*Marfan syndrome Medical Conditions Associated With Secondary Osteoporosis

19. NutritionalMalabsorption syndromes, malnutritionChronic liver diseaseGastric operationsVitamin D deficiencyAlcoholism OtherRheumatoid arthritisMyelomaCertain cancersImmobilizationRenal tubular acidosisHypercalciuriaChronic obstructive pulmonary diseaseOrgan transplantationCholestatic liver diseaseMastocytosisThalassemia Medical Conditions Associated With Secondary Osteoporosis

20. Some Medications that can cause Secondary Osteoporosis • Vitamin D Toxicity • Phenytoin • Glucocorticoids • Phenobarbital • Excessive thyroid hormone replacement • Heparin • Gonadotropin-releasing hormone antagonists

21. How does this obvious bone loss happen? • Bone is a living, growing, tissue • Healthy bones are not quiescent. They are constantly destruction, but imbalance between the formation being remodeled. • This is not simply a problem of bony and destruction of bone. • Two types of bone • Cortical • Trabecular

22. Cortical (Compact) Bone • 80% of the skeletal mass • Provides a protective outer shell around every bone in the body • Slower turnover • Provides strength and resists bending or torsion

23. Trabecular (Cancellous) Bone • 20% of the skeletal mass, but 80% of the bone surface. • less dense, more elastic, and higher turnover rate than cortical bone. • appears spongy • found in the epipheseal and metaphysal regions of long bones and throughout the interior of short bones. • constitutes most of the bone tissue of the axial skeleton (skull, ribs and spine). • interior scaffolding maintains bone shape despite compressive forces.

24. Types of Cells in Bone Tissue

25. Bone Remodeling • OsteoBlasts Build Bone. • OsteoClasts Create Cavities in bone.

26. Bone mass declines with age. • Remodeling occurs at discrete foci called bone remodeling units (BRUs). • Number of active BRUs increase with age, resulting in increased bone turn over. • Osteoblasts are not able to completely fill cavities created by osteoclasts and less mineralized bone is formed. • Endosteal bone loss is partially compensated by periosteal bone formation. This leads to trabecular thinning.

27. Bone Remodeling Unit Osteoclast Osteoblast New bone Lining cells

28. Scanning electron micrograph of slice of osteoporotic cancellous bone from the fourth lumbar vertebra of an elderly woman. • www.grad.ucl.ac.uk

32. Bones are living organs • Calcium is deposited and withdrawn from bones daily. • Bones build to about age 30. • We need to build up a healthy bone account while young and continue to make deposits with age.

33. After mid-30’s, you begin to slowly lose bone mass. Women lose bone mass faster after menopause, but it happens to men too. • Bones can weaken early in life without a healthy diet and the right kinds of physical activity.

34. The good news: Osteoporosis is preventable for most people! • Start building healthy bones while young. • Healthy diet and lifestyle are important for BOTH men and women.

35. Simple Prevention Steps The National Osteoporosis Foundation (NOF) recommends FIVE simple steps to bone health and osteoporosis prevention …

36. Step 1 Get your daily recommended amounts of calcium and vitamin D.

37. Calcium requirements vary by age Growthspurt

38. 600 IU 600 500 400 IU 400 200 IU 300 200 100 0 up to 50 51-70 over 70 You need more vitamin D as you age Daily vitamin D needs inInternational Units (IU) Age

39. What about Vitamin D? Main dietary sources of vitamin D are: • Fortified milk (400 IU per quart) • Some fortified cereals • Cold saltwater fish (Example: salmon, halibut, herring, tuna, oysters and shrimp) • Some calcium and vitamin/mineral supplements

40. Vitamin D from sunlight exposure • Vitamin D is manufactured in the skin following direct exposure to sun. • Amount varies with time of day, season, latitude and skin pigmentation. • 10–15 minutes exposure of hands, arms and face 2–3 times/week may be sufficient (depending on skin sensitivity). • Clothing, sunscreen, window glass and pollution reduce amount produced.

41. Step 2 Engage in regular weight-bearing exercise. Even simple activities such as walking, stair climbing and dancing can strengthen bones.

42. 12 oz. 5 oz. 1.5 oz. Step 3 Avoid smoking and excessive alcohol & soft drinks MyPyramid.gov recommends no more than 1 drink per day for women and 2 for men.

43. Step 4 Talk to your doctor about bone health.

44. Step 5 Have a bone density test and take medication when appropriate. Source of photo: USDA ARS Photo Unit Photo by Peggy Greb Testing is a simple, painless procedure.

45. Diagnostic Outline • What is bone density testing? • Why is it done? • Who should be tested? • When should it be repeated? • How is it interpreted?

46. Why Should We Care About Bone Density? • Osteoporosis is common - >50% of Saudi women have osteoporosis or low bone mineral density (BMD) • Osteoporosis is serious - Osteoporotic fractures cause increased morbidity and mortality • Osteoporosis is easy to diagnose - Bone density testing can detect osteoporosis before the first fracture occurs • Good treatments are available- Fracture risk can be reduced by about 50%

47. Bone Densitometry • Non-invasive test for measurement of BMD • Major technologies • Dual-energy X-ray Absorptiometry (DXA) • Quantitative Ultrasound (QUS) • Quantitative Computerized Tomography (QCT) • Many manufacturers • Numerous devices • Different skeletal sites

48. Indications For Bone Density Testing • All women age 65 and older ( 50 in Saudi) • All men age 70 and older • Adults with a fragility fracture • Adults with a disease or condition associated with low bone density • Adults taking medication associated with low bone density • Anyone being treated for low bone density to monitor treatment effect • Anyone not receiving therapy, in whom evidence of bone loss would lead to treatment Women discontinuing treatment should be considered for bone density testing according to the indications listed above.

49. DXA • “Gold-standard” for BMD measurement • Measures “central” or “axial” skeletal sites: spine and hip • May measure other sites: total body and forearm • Extensive epidemiologic data • Correlation with bone strength in-vitro • Validated in many clinical trials

50. DXA Technology Detector (detects 2 tissue types - bone and soft tissue) Very low radiation to patient. Very little scatter radiation to technologist Patient Collimator (pinhole for pencil beam, slit for fan beam) Photons X-ray Source (produces 2 photon energies with different attenuation profiles)