Understanding Osteoporosis in Perimenopausal and Menopausal Women
Written and edited by Sarah Bonza MD, MPH, FAAFP, DipABLM, NBC-HWC
Introduction
As a physician dedicated to helping menopausal and perimenopausal women reclaim their vitality, I have seen firsthand the profound impact that osteoporosis can have on women’s health. Osteoporosis, a condition characterized by weakened bones and an increased risk of fractures, is particularly prevalent during the perimenopausal and menopausal periods. This blog aims to shed light on the intricacies of osteoporosis, its diagnosis, risk factors, and management strategies.
The Menopausal Transition and Bone Health
The menopausal transition, or perimenopause, typically begins 1 to 3 years before menopause and can last for 5 to 10 years. During this time, women experience a significant decline in estrogen levels, which plays a crucial role in maintaining bone density. Estrogen helps to slow down bone resorption, the process by which bone is broken down and its minerals released into the bloodstream. As estrogen levels drop, bone resorption becomes more rapid, leading to a higher rate of bone loss. Studies have shown that the rate of bone loss is highest around the time of menopause, with an average annual loss of 1–2% [1,2,5].
The Role of Progesterone
Progesterone, another hormone that declines during menopause, also contributes to bone health. Progesterone promotes bone formation by stimulating osteoblasts, the cells responsible for building new bone. Decreased levels of progesterone can therefore contribute to bone weakness and increase the risk of osteoporosis [2,3].
Diagnosing Osteoporosis
Osteoporosis is often called a “silent disease” because it progresses without symptoms until a fracture occurs. The most common method for diagnosing osteoporosis is a bone mineral density (BMD) test, typically performed using dual-energy X-ray absorptiometry (DEXA). This test measures the density of bones in the spine, hip, and forearm and provides a T-score that compares the patient’s bone density to that of a healthy young adult. A T-score of -1 to -2.5 indicates osteopenia (low bone density), while a T-score of -2.5 or lower indicates osteoporosis [9.12].
Consequences of Osteoporotic Fractures
Osteoporotic fractures can have severe consequences, including pain, decreased mobility, and a reduced quality of life. Fractures of the spine, hip, and wrist are particularly common and can lead to long-term disability and increased mortality. Preventing these fractures is a critical aspect of managing osteoporosis [10,11].
Risk Factors for Low Bone Mineral Density
Several factors increase the risk of low bone mineral density and osteoporosis, including:
1.Advanced age
2.Thinness or low body weight
3.Genetic predisposition
4.Smoking
5.History of fractures
6.Certain diseases (e.g., rheumatoid arthritis, diabetes)
7.Long-term use of certain medications (e.g., glucocorticoids) [6,7,8,13]
Indications for Bone Mineral Density Testing
Bone mineral density testing is recommended for:
- Women aged 65 and older
- Postmenopausal women under 65 with risk factors for osteoporosis
- Individuals with a history of fractures after age 50
- Those with conditions or medications associated with bone loss [9,12,14]
Management of Osteoporosis
Lifestyle Measures
- Vitamin D and Calcium: Essential for bone health, with recommended daily intakes of 800 IU of vitamin D and 1200 mg of calcium.
- Protein Intake: Higher protein intake is associated with reduced fall frequency.
- Magnesium: Low magnesium levels are linked to low bone mineral density; supplementation can be beneficial.
- Vitamin K: Promotes the carboxylation of osteocalcin, a protein involved in bone mineralization.
- Phytoestrogens: Compounds like soy isoflavones have modest estrogen-like effects on the skeleton [4,6,7].
Pharmacologic Agents
- Systemic Estrogen Therapy: Helps maintain bone density but may have side effects.
- Selective Estrogen Receptor Modulators (SERMs): Raloxifene and bazedoxifene can help, though raloxifene may worsen hot flashes.
- Bisphosphonates: Alendronate, risedronate, ibandronate, and zoledronic acid impair osteoclast activity, reducing bone resorption.
- Denosumab: A monoclonal antibody that inhibits bone remodeling by binding to RANK ligand.
- Parathyroid Hormone Receptor Agonists: Teriparatide and abaloparatide stimulate bone formation and are the only agents that promote new bone growth [4,14].
Conclusion
Osteoporosis is a significant concern for perimenopausal and menopausal women, but with early diagnosis and a comprehensive management plan, its impact can be mitigated. By focusing on lifestyle measures, appropriate supplementation, and pharmacologic treatments, we can help women maintain strong bones and reduce the risk of fractures. As always, personalized care and regular monitoring are key to effective osteoporosis management.
REFERENCES:
(1) Evaluation of Bone Mineral Density in Perimenopausal Period — PMC](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5799602/)
2) Progesterone and Bone: Actions Promoting Bone Health in Women](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2968416/)
(3) Progesterone for the prevention and treatment of osteoporosis in (https://www.tandfonline.com/doi/full/10.1080/13697137.2018.1467400)
(4) Pharmacological Therapy of Osteoporosis: A Systematic Current (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682013/)
(5) Bone and the Perimenopause — PMC — NCBI](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920744/)
(6) A comprehensive overview on osteoporosis and its risk factors — PMC](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225907/)
(7) Osteoporosis Due to Hormone Imbalance: An Overview of … — NCBI](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836058/)
(8) Osteoporosis: What You Need to Know as You Age](https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteoporosis/osteoporosis-what-you-need-to-know-as-you-age)
(9) Bone Densitometry | Johns Hopkins Medicine](https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/bone-densitometry)
(10) Diagnosis and treatment of osteoporotic fractures — PMC — NCBI](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583415/)
(11) Menopause and Bone Loss | Endocrine Society](https://www.endocrine.org/patient-engagement/endocrine-library/menopause-and-bone-loss)
(12) Bone Mineral Density Test: Purpose, Procedure, and Results — WebMD](https://www.webmd.com/osteoporosis/bone-mineral-density)
(13) Osteoporosis and Menopause — WebMD](https://www.webmd.com/menopause/osteoporosis-menopause)
(14) Diagnosis and Management of Osteoporosis — AAFP](https://www.aafp.org/pubs/afp/issues/2015/0815/p261.html)
