Management of Osteoporosis in postmenopausal women

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After reaching peak bone mass a progressive bone loss begins shortly, which is expected to be higher in women after menopause. In this critical life-period of women early secondary prevention is essential. Prevention of osteoporosis is a necessity for people who have low bone density and more than one risk factors for osteoporosis.

Because early menopause is the most important predisposing factor is usually required to prevent these women, especially in the first five postmenopausal years. Finding women losing bone density with an increased rate of bone loss (fast bone losers) is generally an expanding prevention method, whether they have early menopause or ovariectomy. In the postmenopausal period (i.e. 6 months after the last menstruation), all women should do bone densitometry measurement. The goal of preventive treatment is to stabilize the rate of decrease in bone density or even the halting of bone loss.

Secondary prevention of osteoporosis can be made with respect to the following plan:

1) Medications used to treat osteoporosis

Estrogen relieves menopausal symptoms, has beneficial effects in maintaining bone mass and helps prevent postmenopausal osteoporosis. It is first choice therapy in women with menopause below 48 years but now days are a second choice drug in the treatment of postmenopausal osteoporosis because their use is risky. These risks are the development of endometrial cancer, developing breast cancer and thromboembolic disease. All women undergoing hormone replacement therapy should undergo regular mastography check.

A great progress in recent years is the creation of drugs (SERMS, raloxifene) that while helping to prevent osteoporosis and lowering cholesterol, have no action on the breast and uterus. In this way it hopes to improve compliance in the treatment of postmenopausal women.

Calcitonin is a bone-specific hormone that blocks the action of osteoclasts. This hormone is rather without serious side effects than to induce nausea and hot flashes after intramuscular shot. Indeed, after receiving calcitonin bone loss is suspended, while increased values of bone density are possibly expected. The intranasal administration of this medicine is recently considered practical. Furthermore, calcitonin has an analgesic activity, especially after vertebral fractures.

Bisphosphonates (pamidronate, alendronate, risedronate, ibandronate, zolendronic acid). They inhibit bone loss by destroying the osteoclasts. Bisphosphonate drugs p.os are hardly absorbed from the intestine, therefore required to be taken by standing, in an empty stomach and with a large quantity of water. The tolerance of bisphosphonates has been improved even further with the weekly administration of alendronate and risedronate and the monthly ibandronate and risendronate. Currently, intravenously bisphosphonates are used as a yearly infusion (zoledronic acid) and quarterly injection (ibnandronate), when there are such indications. These drugs reduce the risk of fracture in the spine and hip.

The treatment of osteoporosis is developed with the administration of anabolic drugs. Representatives of this group are PTH and teriparatide (1-34 PTH), which state that can increase bone mass by 10% per year, and strontium. Lately, another antiresoptive drug under the name denosumab is introduced.

2) Modifying nutrition and lifestyle habits in postmenopausal women predisposing to osteoporosis, namely:

a) Increase the intake of dairy products and calcium supplementation by mouth, in order to reach 1500 mg of calcium per day. The importance of calcium to prevent osteoporosis has become a matter of extensive research and studies found that high calcium intake may reduce the rate of postmenopausal loss in half. Similarly, it appears that calcium helps maintain a higher bone density of the spine.

When the daily intake of calcium in postmenopausal life is less than 800 mg spinal osteoporosis is developed. Studies have shown that exercise contributes to the current calcium intake to maintain bone density. In elderly, calcium administered in high doses, can reduce the incidence of hip fractures. Increased calcium intake helps maintain a positive balance of calcium.

b) Exposure to sunlight or supplemental vitamin D. Lack of vitamin D can easily be treated by administration of small doses of vitamin D (i.e. 400 IU D3 per day).

c) Stop smoking.

d) Suspension of alcoholic beverages.

e) Reducing the intake of animal protein.

f)  Increasing musculoskeletal activity by integrating patient specific therapeutic exercise programs.

4) Treatment of diseases that predispose to osteoporosis, for example hyperthyroidism, digestive diseases that cause diarrhea and general conditions which prevent the absorption of calcium, etc.

 

After 65 years of age the effects of postmenopausal osteoporosis are visible (fractures-established osteoporosis), while beginning the process of senile osteoporosis, mainly through reduced absorption of calcium from the intestine and decreased osteoblastic activity. Impairments in basic sensors (vision, hearing) and mainly imbalance increase the risk of falls and thus multiplying the risk of osteoporotic fractures. The tertiary prevention in this age, aims to address the above causes. Thus, in the third age strategy of prevention should focus on:

1) Prevention of falls.

2) Assist the intestinal absorption of calcium.

3) Pain treatment and improvement of locomotor activity.

 

3) The therapeutic intervention with various types of orthoses in the prevention and treatment of spinal fractures from osteoporosis

A new introduced orthosis called Spinomed is created for patients with severe back pain from osteoporosis and vertebral fractures. The mechanism action is achieved by biofeedback, namely the orthosis is following the movements of the patient, and recalls the right posture, so that the patient actively with his own muscles corrects posture and avoids wrong posture patterns. Another multifactional orthosis called Osteomed, reduces pain and promotes mobility. It relies on gate control theory. The use of a spinal orthosis improves the strength of dorsal and ventral trunk muscles, reduces pain, reduces kyphosis and constraints of everyday life.

 

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Yannis Dionyssiotis, MD, PhD, FEBPRM, Director of Physical and Social Rehabilitation Center Amyntaeo, Florina, Greece, e-mail:yannis_dionyssiotis@hotmail.com
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