phosphate intake (Michael F. Holick; Wilson Terrace, 2013). Furthermore Physical factors include sedentary lifestyle, low. Body Mass Index (BMI) and lack of sun ...
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
7
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
10
[5]. Compston, J., Bowring, C., Cooper, A., Cooper, C., Davies, C., & Francis, R. et al. (2013). Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013. Maturitas, 75(4), 392--396. [6]. Delaney, M. (2006). Strategies for the prevention and treatment of osteoporosis during early postmenopause. American Journal Of Obstetrics And Gynecology, 194(2), 12--23. [7]. El-Heis, M., Al-Kamil, E., Kheirallah, K., Al-Shatnawi, T., Gharaibia, M., & Al-Mnayyis, A. (2013). Factors associated with osteoporosis among a sample of Jordanian women referred for investigation for osteoporosis. Eastern Mediterranean Health Journal, 19(5). [8]. El-Mekawy, H., Dein, E., & Salah, L. (2012). Exercise Programs for Treating Post Menopausal Osteoporotic Women; Which is Best?. Indian Journal Of Physiotherapy & Occupational Therapy, 6(4). [9]. Giangregorio, L., MacIntyre, N., Heinonen, A., Cheung, A., Wark, J., & Shipp, K. et al. (2014). Too Fit To Fracture: a consensus on future research priorities in osteoporosis and exercise. Osteoporosis International, 25(5), 1465--1472. [10]. Gourlay, M., Fine, J., Preisser, J., May, R., Li, C., & Lui, L. et al. (2012). Bone-density testing interval and transition to osteoporosis in older women. New England Journal Of Medicine, 366(3), 225--233. [11]. Hamrick, I., Cao, Q., Agbafe-Mosley, D., & Cummings, D. (2012). Osteoporosis Healthcare Disparities in Postmenopausal Women. Journal Of Women's Health, 21(12), 1232--1236. [12]. Holloway, D. (2011). An overview of the menopause:
i-manager’s Journal on Nursing, Vol. 4 l No. 2 l May - July 2014
ARTICLES assessment and management. Nursing Standard, 25(30),
[21]. National Institute on Aging, (2014). Postmenopausal
47--57.
Health Concerns. Retrieved 22 May 2014, from
[13]. Iofbonehealth.org,. (2014). World Osteoporosis Day |
http://www.nia.nih.gov/health/publication/menopause-
International Osteoporosis Foundation. Retrieved 22 May
time-change/postmenopausal-health-concerns
2014, from http://www.iofbonehealth.org/world-
[22]. Ross, J. (2009). Osteoporosis-the fall that causes the
osteoporosis-day
fracture. Pod Mgmt, 28(5), 195--204.
[14]. Jamal, S., Dion, N., & Ste-Marie, L. (2011). Atypical
[23]. Sadler, C., & Huff, M. (2007). African-American
femoral fractures and bone turnover. New England Journal
women: health beliefs, lifestyle, and osteoporosis.
Of Medicine, 365(13), 1261--1262.
Orthopaedic Nursing, 26(2), 96--101.
[15]. Kanis, J., Burlet, N., Cooper, C., Delmas, P., Reginster,
[24]. Schnatz, P., Barker, K., Marakovits, K., & O'Sullivan, D.
J., Borgstrom, F., & Rizzoli, R. (2008). European guidance for
(2010). Effects of age at first pregnancy and breast-
the diagnosis and management of osteoporosis in
feeding on the development of postmenopausal
postmenopausal women. Osteoporosis International,
osteoporosis. Menopause, 17(6), 1161--1166.
19(4), 399--428.
[25]. Shakil, A., Gimpel, N., Rizvi, H., Siddiqui, Z., Ohagi, E.,
[16]. Keen, R. (2007). Osteoporosis: strategies for
Billmeier, T., & Foster, B. (2010). Awareness and prevention
prevention and management. Best Practice & Research
of osteoporosis among South Asian women. Journal Of
Clinical Rheumatology, 21(1), 109--122.
Community Health, 35(4), 392--397.
[17]. Lowe, N., Ellahi, B., Bano, Q., Bangash, S., Mitra, S., &
[26]. Surangtip, S., Sakondhavat, C., Soontrapa, S.,
Zaman, M. (2011). Dietary calcium intake, vitamin D status,
Kaewrudee, S., & Somboonporn, W. (2012). Prevalence of
and bone health in postmenopausal women in rural
osteoporosis in postmenopausal women at Srinagarind
Pakistan. Journal Of Health, Population, And Nutrition, 29(5),
Hospital, Khon Kaen University. Thai Journal Of Obstetrics
465--470.
And Gynaecology, 18(1), 26--34.
[18]. Melton, L., Chrischilles, E., Cooper, C., Lane, A., &
[27]. Wells, G., Tugwell, P., Shea, B., Guyatt, G., Peterson, J.,
Riggs, B. (2005). How many women have osteoporosis?.
& Zytaruk, N. et al. (2002). Meta-analyses of therapies for
Journal Of Bone And Mineral Research, 20(5), 886--892.
postmenopausal osteoporosis. V. Meta-analysis of the
[19]. Nagi, D., Butt, Z., Farooq, F., & Aamar, A. (2013).
efficacy of hormone replacement therapy in treating and
Frequency of osteoporosis in an ambulatory setting in
preventing osteoporosis in postmenopausal women.
Lahore using quantitative calcaneal ultrasound. JOURNAL
Endocrine Reviews, 23(4), 529--539.
OF THE PAKISTAN MEDICAL ASSOCIATION, 63(8), 965--968.
[28]. Zahoor, S., & Ayub, U. (2010). Prevalence of
[20]. Najam, R., & Huda, N. (2012). Assessment of
osteoporosis in postmenopausal women visiting police &
Osteoporosis in Post Menopausal Women: A Clinical Study.
services hospital, Peshawar, NWFP. JPMI: Journal Of
Nepal Journal Of Obstetrics And Gynaecology, 6(2), 11--
Postgraduate Medical Institute, 24(1).
13.
i-manager’s Journal on Nursing, Vol. 4 l No. 2 l May - July 2014
11