Post Menopause and Osteoporosis

Preventing bone loss is an important concern for women in the menopause and during post-menopausal stages. Menopause significantly speeds bone loss and increases the risk for osteoporosis. Research indicates that up to 20% of bone loss can happen during these stages and approximately 1 in 10 women over the age of 60 are affected by osteoporosis worldwide.

Osteoporosis is a disorder associated with low bone mass where bones become naturally weak, increasing the likelihood of fractures (bone breaks). Bones in the hip, spine, and wrist are especially prone to fragility fractures in older adults with little or no evidence of trauma. Osteoporosis is more common in women because menopause can accelerate bone loss causing the bones to break down more quickly than it is formed.

Common risk factors that can put you at an early risk for developing osteoporosis:

• Early menopause (before 45)
• Removal of the ovaries
• Chemotherapy treatment

Terms you should know

Osteoporosis: a progressive condition in which bones become structurally weak and are more likely to fracture or break

Osteopenia: low bone mineral density where the body does not make new bone as fast as the old bone is absorbed

Bone turnover markers: a test in the laboratory of bone resorption or bone formation

BMD: bone mineral density is the amount of calcium and other minerals in your bone tissue

DXA: Dual energy x-ray absorptiometry a test to measure bone mineral density (BMD)

T-score: the units of standard deviation away from the mean for a 35-year-old woman measured by bone mineral density; a negative score means lower bone mineral density than a 35-year-old woman

(FRAX) fracture risk assessment: a measure of the vertebrae to assess whether it has fractured using bone density measurements

How is Osteoporosis Diagnosed?

Osteoporosis is often called “a silent disease” usually determined with the first fracture. It can also be diagnosed by measuring the reduction of bone density. However, any fracture in postmenopausal women or in elderly men can be considered due to osteoporosis unless related to a motor vehicle accident or major trauma. Common symptoms include:

• Back pain if there are small fractures, or if vitamin D is extremely low
• Loss of two inches in height is a sign of vertebral bone collapse
• Kyphosis or a hunchback appearance in the advanced stage
• Bone fractures due to weakening from osteoporosis common in hip, wrist, and spine

Hormones and Osteoporosis

As hormones change to accommodate normal menopausal changes, estrogen levels start to fluctuate and then drop. Estrogen helps prevent bones from getting weaker by slowing the natural breakdown of bone. Menopause is the most common cause of osteoporosis. One in two postmenopausal women will have osteoporosis and most will suffer a fracture during their lifetime. Fractures (bone break) cause pain, decreased mobility, and function. Fear of falling and are associated with decreased quality of life and increased mortality.

Prevention and Treatment

It is never too late to be treated for osteoporosis, and in fact, older women are more likely to respond better to treatment if given early. The goal of your treatment plan is to decrease fractures associated with osteoporosis and maintain good bone health. Lifestyle changes that can improve bone health are:

• Customized exercise regimen that support proper maintenance of the skeleton, including resistance, balance and weight- bearing exercises
• Eat a balanced diet that include: calcium-Vitamin D and Calcium rich foods, dairy products fortified with vitamin D, and fish if possible
• Sunshine is important to keep vitamin D levels adequate
• Preventing obesity will help keep bones strong
• Avoid smoking
• Limit alcohol consumption

There are many drugs and hormone therapies available to prevent further bone loss and to stimulate new bone formation. Any fracture occurring after menopause should be considered an osteoporotic fracture and should be aggressively treated with one of several possible drugs or therapies:

• Bisphosphonates – Oral medication used to prevent and treat postmenopausal osteoporosis by slowing bone loss while increasing bone mass
• Denosumab- IV medication that lowers the risk of fractures (bone breaks) and blocks bone loss
• Abaloparatide or Teriparatide- Parathyroid hormone which increases bone mass by stimulating bone formation and bone turn over
• Romozozumab- A "sclerostin blocker" injected monthly in the doctor's office for 12 months. It's recommended for post-menopausal women at very high risk for fractures. 
• Tibolone – hormone therapy that helps to relive menopause symptoms and prevent osteoporosis (not available in the U.S. or Canada
• Calcitonin- nasal spray used to regulate calcium levels in the body
• Calcium and Vitamin D Supplement- enhance bone formation and prevent fractures
• Estrogen-hormone therapy prevents osteoporosis by reducing the breakdown of bone, what is also called bone resorption.

Current treatments are very effective and lower the risk of further harm. Duration of treatment will vary depending on a women’s fracture risks, long-term effects of therapy on bone health, and other risks or side effects. Treatments should be a shared decision with you and your healthcare team.

Questions to Ask Your Healthcare Team

• How low is my bone density?
• Am I considered high risk for fractures?
• Do I need treatment, or can I wait?
• What are the side effects of the treatment you are recommending?
• Should I be taking supplemental calcium and vitamin D?
• Should I see an endocrinologist or any other specialist?

Developed for patients based on Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline