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ARTICLES

OSTEOPOROSIS IN POST-MENOPAUSAL WOMEN By AFSHEEN HIRANI *

SANIA RUPANI *****

NEELUM NASIRUDDIN ****

MUNIZA MOMIN ***

ARIFA FEHMI **

UMER HAIDRI ******

ZOYA KHOWAJA *******

*-**-***-****-*****-******-******* Students, Aga Khan University School of Nursing and Midwifery Karachi.

ABSTRACT Post-menopausal women face many physical, physiological and psychological alterations due to hormonal changes. Osteoporosis is one of the major bone health issues faced by them and it is the main cause of fracture incidences and disabilities. This paper defines the issue in detail along with its major causes. It explores the prevalence and incidence of post-menopausal osteoporosis worldwide and specifically in Pakistan. Furthermore, it discusses about the wide variety of treatments which includes pharmacological and non-pharmacological ways i.e. diet and exercises. Moreover, it provides the preventive measures and recommendations and also explores the future research needs. By working on them, women can fight with osteoporosis and other bone health issues which can reduce the morbidity and mortality rates among women. Keywords: Osteoporosis, Post-Menopause, Hormonal changes, Prevalence, Pakistan. INTRODUCTION

bone densities more than 2.5 standard deviations (SD),

Osteoporosis is a worldwide common and major public

below the mean bone density of healthy young adult

health concern with high prevalence and incidences not

women corresponding to a T-score of ≤-2.5” (Ross, 2009). In

only in western areas but also in Asia. Literal meaning of

post-menopausal women, low levels of estrogen disturb

osteoporosis is “porous bone”. It is a multifactorial skeletal

the normal cycle of bone formation. This increases the

disorder which leads to low bone mineral density and is the

activity of bone resorbing cells rather than bone forming

major cause of fracture incidences, disabilities, reduced

cells and makes a person vulnerable to spine, hip and wrist

mobility and poor quality of life. According to Nagi (2013),

fractures. The average loss of Bone Mineral Density (BMD) is

the prevalence of osteoporosis is estimated at over 200

estimated as 1%-5% per year. Due to which half of the

million worldwide, of whom 44 million patients are from the

women suffering from osteoporosis have the chances of

US and 9.9 million are from Pakistan. From those 9.9 million,

developing fractures (Cabrera, 2013). That's why Ross

7.2 million are women and from those women, post-

(2009), mentioned this disorder as “Silent disease” because

menopausal women are more prone to develop

the symptoms are hidden until and unless fracture occurs. It

osteoporosis. Due to the drastic increase in its incidences

is beneficial to identify osteoporosis at initial stage and early

among women, International Osteoporosis Foundation

detection can be done by measuring BMD and Dual

selected the theme of world osteoporosis day (20th

Energy X-ray Absorptiometry (DEXA).

October 2013) as “Post-menopausal women and their

Epidemiological Aspect

bone health”. This is the reason for selecting this topic for

According to National osteoporosis foundation (2010), out

scholarly writing. Its higher incidence in women is related to

of total osteoporosis patients in the US, 80% are females

post-menopausal changes, lesser bone mass, smaller

and only 20 % are males. Furthermore, The Third national

bone size and longer life as compared to men (Moseley,

health and nutrition examination survey shows that

2010).

American Women of age 50 and older are more likely to

WHO stated that “Women are osteoporasis, if they have

have osteoporosis and low BMD as compared to younger

i-manager’s Journal on Nursing, Vol. 4 l No. 2 l May - July 2014

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ARTICLES women. Research concluded that osteoporosis are

Furthermore Physical factors include sedentary lifestyle, low

accountable for 90% of all hip and spine fractures in

Body Mass Index (BMI) and lack of sun exposure. Other

American women ages 65 to 84 and it increases the

contributing elements are medications like heparin,

mortality rate. According to Chuanchom Sakondhavat,

corticosteroids and chemotherapy, medical conditions

Surangtip Thangwijitra, Sukree Soontrapa, Srinaree

such as chronic liver disease, malabsorption syndrome,

Kaewrudee and Woraluk Somboonporn (2009) the chances

hyperthyroidism, inflammatory bowel disease, Diabetes

of osteoporosis and related fractures are more common

Mellitus and renal failure. Lifestyle factors consist of high

among Asian women as compared to Asian men.

caffeine consumption and smoking habits which reduce

Shafaq Zahoor and Umar Ayub (JPMI, 2010) stated in their

the estrogen and calcium absorption. (M.A. El-Heis ; Laura

study that 8.4 million from total 70 million women in Pakistan

Boehnke; Cheryl Sadler). Rodica Torok (2013) mentioned in

are above 50 years and are having osteoporosis. In

his study that alcohol consumption is the least frequent risk

addition, a cross sectional study from May-August 2004 in

factor.

Karachi concluded that most of the post-menopausal

Non Pharmacological and Pharmacological Treatment

women had decreased bone mineral density and were

All women of menopausal status should draw their concern

having osteopenia (43.1%) and osteoporosis (49.3%)

to the risk factors of bone loss and fracture. The solution

(Lubna Baig, Farah Asad Mansuri and Saadiya A. Karim,

consists of pharmacological and non-pharmacological

2009). Additional study conducted at Akhtar Saeed Trust

ways. Non-pharmacological management includes diet

Teaching Hospital, Lahore; from July to December 2011

and exercise.

determines that the occurrence of osteoporosis was found to be common among females over 45 years of age (41.3%) more than males over 45 years of age (20.6%). (Daniyal Nagi, Zeeshan Butt, Ali

Aamar, Fariha Farooq,

August 2013). Thus, all studies concluded that it is more common among women who are in their postmenopausal phase than any other subgroup.

Appropriate diet comprises of optimum intake of calories, calcium and vitamin D. Foods enriched in calcium are milk and milk products, canned fish with soft bones, such as salmon, dark-green leafy vegetables, and foods with calcium added, like orange juice, bread, and cereals. (Miriam F. Delaney, 2006). Vitamin D is required for absorption of calcium, therefore it's necessary to add

Causes

vitamin D in our diet. Sunlight is one of the most important

According to National Institute of Health (2013), the major

sources for vitamin D consumption. Other sources are milk

cause of osteoporosis in post-menopausal women

fortified with vitamin D, Cereals, Fatty fish and eggs.

includes Low levels of serum FSH and estrogen which

In addition, all post-menopausal women should be

usually occurs in late menarche and early menopause.

counseled regarding the benefits of regular physical

Moreover, Peter (2010), mentioned that women with a first

exercise to prevent from osteoporosis. Walking, running,

pregnancy at age 27 or older and history of breastfeeding

stair climbing and weight bearing exercise can help to

is less prone to osteoporosis as compared to women who

keep our bones strong if done at least three or four times a

had a first pregnancy before 27 years or had no history of

week. Moreover, The Erlangen Fitness Osteoporosis

breastfeeding. Along with it, genetic factors and family

Prevention Study showed that aerobic, weight-bearing,

history are also accountable. Rodica Torok (2013) stated

strength training, and stretching exercises increased

that “The genetic factor appears to be much more

lumbar spine BMD by 1.3% over 14 months in

important in osteoporosis pathogenesis than the

postmenopausal women. (Miriam F. Delaney, 2006).

combination of dietary, hormonal, environmental and lifestyle factors”. In addition, nutritional reasons are responsible like low calcium, low vitamin D intake and high phosphate intake (Michael F. Holick; Wilson Terrace, 2013).

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On the other hand, pharmacological management is used along with non-pharmacological measures. Bisphosphonates are advised as a first line therapy for postmenopausal osteoporosis. These are the binders of

i-manager’s Journal on Nursing, Vol. 4 l No. 2 l May - July 2014

ARTICLES phosphates and calcium, which helps in active bone

Preventive strategies and recommendations

remodeling. Intravenous Ibandronate is licensed for the

As osteoporosis are ver y common among

treatment of post-menopausal osteoporosis, given as 3

postmenopausal women in Pakistan so following

mg every 3 months (Richard Keen, 2007). In a two year

recommendations and strategies can be useful to reduce

study of early postmenopausal women (1-3 years since

the incidences. Firstly, at government level, as an adviser

menopause) without osteoporosis, daily Ibandronate

we can suggest to make policies to reduce the causes and

maintained or increased BMD at the hip and the spine

decrease the incidence to reduce the prevalence. Shakil

(Miriam F. Delaney, 2006). Similarly, Strontium Ranelate can

(2010) recommended that preclinical assessment, clinical

be preferred as alternative therapy against

trials and approval of new drugs for osteoporosis should be

bisphosphonate. It is approved by the European Union for

taken into account according to WHO guidelines. Self-help

the treatment of post-menopausal osteoporosis (Richard

groups and osteoporosis awareness programs in affiliation

Keen, 2007).

with other organizations should be planned for women

Besides this, a meta-analysis data has proven that

above 45 and with multiple risk factors, to create

Hormone Replacement Therapy (HRT) drastically reduces

awareness and encourage people for taking steps for

the risk of vertebral and non-vertebral fractures; these

prevention and treatment before reaching severe

results have also been confirmed from the Women's Health

conditions.

Initiative (WHI) (Richard Keen, 2007). Still, after having so

It is recommended that every woman above 30 should

many advantages of the therapy researchers have come

take Calcium and vitamin D supplements and fortified

up with major health issues caused by this therapy are

foods. Along with it, timely vitamin D injections should also

breast cancer, myocardial infarction, stroke and venous

be taken. In addition, screening should be done after

thromboembolic events. That's why it is not commonly used

menopause to prevent from consequences. Women who

(Richard Keen, 2007).

are already suffering from osteoporosis should opt for

Selective Estrogen Receptor Modulators (SERMs) are also

medications along with non-pharmacological ways.

used and they produce the same effect like estrogen in the

Researchers recommend Bisphosphonates as first line

bones. These medications provide protection against

treatment, but it should be avoided in patients with renal

bone loss. Additionally, 1000-1500 mg/day of calcium and

impairment Patients who are on HRT should be counseled

400-800 IU/day vitamin D daily are prescribed by a

for the side effects of therapy and suggest them for regular

physician. Due to estrogen withdrawal in post menopausal

screening for breast cancer and other risk factors (Richard

women, calcium is least likely to affect (Richard Keen,

Keen, 2007). Optimum calcium and vitamin D intake are

2007).

beneficial, but intake of calcium should be avoided at

Furthermore, Parathyroid hormone can be used as well.

bedtime as it increases bone resorption (J.J, 2014).

Research has shown that it reduces the risk of vertebral

According to El-Mekawyl (2012) brisk walking daily for 30

fractures by 65% and non-vertebral fractures overall by

minutes and weight bearing exercises on a treadmill are

53% (Richard Keen, 2007). McClung (2014) mentioned in

helpful in prevention and treatment so at community level,

his study that 30 mg of Denosumab every three months

we can suggest providing fitness center facilities and

and 60 mg every six months can be used for increasing

allocating specific hours for women and encourage them

bone density.

to participate.

The least used pharmacological agent is calcitonin. It is

Moreover, in collaboration with NGO's and different

regarded as analgesics for the patient to complain of pain.

institutions we can organize an event on World

It is not recommended to use as a first line therapy to

Osteoporosis day, i.e. 20th October every year in Pakistan in

prevent fractures. Furthermore, its physiological

order to create awareness about prevention, diagnosis,

mechanism is still poorly understood (Richard Keen, 2007).

treatment and ways for secondary fracture prevention.

i-manager’s Journal on Nursing, Vol. 4 l No. 2 l May - July 2014

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ARTICLES Research needs

the global longitudinal study of osteoporosis in women

Further research includes the study of incidence and

(GLOW) cohort. Archives Of Osteoporosis, 8(1-2), 1--9.

prevalence of post-menopausal osteoporosis in Pakistan

[3]. Bonnick, S. (2006). Osteoporosis in men and women.

and other developing countries as well as variation of post-

Clinical Cornerstone, 8(1), 28--39.

menopausal osteoporosis among women across different

[4]. Chang, K., Center, J., Nguyen, T., & Eisman, J. (2004).

parts of the globe. There is a need for the development of

Incidence of hip and other osteoporotic fractures in elderly

inexpensive BMD tools and evaluation of biochemical

men and women: Dubbo Osteoporosis Epidemiology

indicators for assessing fracture risk and checking response

Study. Journal Of Bone And Mineral Research, 19(4), 532--

to therapies (Keen, 2007). Additional investigation is

536.

needed to identify diagnostic thresholds at various anatomic sites to compare the severity of osteoporosis. More exploration is needed about the optimum time period for bisphosphonate therapies and identification of alternatives For PTH therapy as many other systemic effects are caused due to PTH excess so more research work should be done on bone forming agents (Mc Clung, 2014). Keen (2009) suggested that studies should be conducted for linking cases of osteoporosis fractures with fall prevention programs. Last but not the least it is necessary to assess cost utility ratio for screening tests so that resources and financial budget could be divided equally. There is immense need to evaluate effect of all therapeutic interventions on the client's quality of life and activity needs. Conclusion In conclusion, Osteoporosis is one of the major concerns globally. Its prevalence is higher in post-menopausal women than any other subgroup. The chief causes are the lower levels of FSH and estrogen, which lead to increased osteoclastic and decreased osteoblastic activities. Along with it other factors like genetic, physical, nutritional, medical and lifestyle make a person more vulnerable. The management includes diet, exercise and medications. The recommendations and work on research needs able to come up with better outcomes in the future. References [1]. Agrawal, V., & Gupta, D. (2013). Recent update on osteoporosis. International Journal Of Medical Science & Public Health, 2(2). [2]. Barcenilla-Wong, A., Chen, J., & March, L. (2013). Concern and risk perception of osteoporosis and fracture among post-menopausal Australian women: results from

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