Prevention of bone loss and fractures in women

Osteoporosis in Post-Menopausal Women: Implications for Occupational Therapy Practice

This paper reviews the literature on intervention considerations with post-menopausal osteoporotic women, with the aim of proposing a potential role for occupational therapists with this population. Postural retraining, exercise, dietary counselling, energy conservation, safety, and psychological counselling are identified as important aspects of treatment relevant to occupational therapy practice.

Heterogeneity of trabecular and cortical postmenopausal bone loss: a longitudinal study with pQCT

Eighty-one women were studied longitudinally to measure trabecular bone mineral density (BMDTrab) and cortical bone mineral density (BMDCorti) in the distal radius by peripheral quantitative computed tomography (pQCT) at intervals of about 1 year and to calculate the rate of percent change/year. Fifty-three women were naturally postmenopausal [mean age 63.3 +/- 5.3 years, age at menopause 50.7 +/- 3.8 years, 13 years since menopause (YSM)] and 28 had been ovariectomized (mean age 52.7 +/- 5.8 years, age at menopause 39.5 +/- 5.0 years, 13 YSM). There was no difference between groups (ANOVA) in the rate of percent change/years in BMDTrab (p = 0.692), but there was in BMDCorti (p = 0.020). When the women who had either gained or lost bone mass were compared (chi-square test), only BMDCorti differed significantly (p = 0.018). Considering > -2.5% change/years as the limit for rapid bone mass loss, BMDTrab values showed that 43% of the naturally postmenopausal women and 42.7% of the ovariectomized women had rapid bone loss (p ns). On the basis of BMDCorti values, 45% of the naturally postmenopausal women and 28.4% of the ovariectomized women had rapid bone loss (p = 0.018). Height, weight, body mass index (BMI), age, YSM, and years of reproductive life did not differ (ANOVA) between the women who gained or lost either BMDTrab or BMDCorti. Using Fisher's r to z and partial correlation adjusted for age and YSM of the percent change/year in BMDTrab and BMDCorti in the overall group and in each menopausal group, only BMDCorti differed.

Prophylaxis of osteoporosis with calcium, estrogens and/or eelcatonin: comparative longitudinal study of bone mass

OBJECTIVE

To evaluate three different therapeutic regimens for the prevention of osteoporosis in natural and surgical postmenopausal women who had been found to have rapid bone loss in analytical studies.

METHODS

A total of 104 naturally or surgically postmenopausal women were studied, and subsequently followed-up during 1 year for avoidance of the influence of seasonal variation on bone mass, a factor overlooked in several studies. They were randomized into four groups of 26 patients each: the untreated control group (mean age 50 +/- 5 years); the hormonal replacement treatment (HRT) group (mean age 48 +/- 6 years), which was treated for 24 days each month with transdermal 17 beta-estradiol, 50 mg/day, together with medroxiprogesterone, 10 mg during 12 days; the calcium group (mean age 50 +/- 4 years), which was treated with elemental calcium, 1 g/day; and the calcitonin group (mean age 50 +/- 5 years), which was treated for 10 days each month with eel calcitonin, 40 IU/day and with elemental calcium, 500 mg/day. Full-body bone densitometry, for measuring total body bone mineral content (TBBMC), was carried out in all the women at baseline and 1 year. TBBMC was corrected for body weight by dividing its value by body weight (TBBMC/W).

RESULTS

After 1 year TBBMC/W was lower in every group: -2.14% (P < 0.001) in the control group; -0.14% (P = NS) in the HRT group (P < 0.05 vs. controls); -0.18% (P = NS) in the calcium group (P < 0.05 vs. controls); and -0.06% (P = NS) in the calcitonin group (P < 0.01 vs. controls; P < 0.05 vs. calcium and HRT).

CONCLUSIONS

These findings show that all three treatments are effective in the prevention of postmenopausal loss of bone mass.

Linear densitometry and digital image processing of proximal femur radiographs: implications for archaeological and forensic anthropology

Age- and sex-related patterns of proximal femur trabecular bone loss have previously been used to establish radiographic reference standards for estimating age at death for human skeletal remains. Such standards are of interest to both anthropologists and forensic scientists. However, osteopenia as a physiological phenomenon is dependent on numerous genetic, environmental, and cultural factors. Thus, while general age- and sex-related trends can be clearly observed for trabecular bone loss, such patterns also demonstrate marked variation among individuals of both sexes at all ages. Moreover, clinical evidence shows that rates of bone loss are not steady but episodic, and that radiographically "normal" (i.e., young adult) patterns of trabecular bone architecture can also exist in femora of older individuals, particularly within samples of African origin. In this study, adult proximal femur radiographs were used to explore patterns of age- and sex-related proximal femur cancellous bone involution among a sample of 66 African-American individuals from the Terry collection (33 males and 33 females), ranging in age from 19 to 71 years. The proximal femur radiographs of these subjects were analyzed by digital image processing (DIP), and the results were compared to those obtained by laser linear densitometric analyses (LDA) previously performed on the same series (Macchiarelli et al., 1987). Results of LDA and DIP analyses indicate (a) more pronounced bone density decrease in females; (b) sex- and site-specific structural patterns of proximal femur trabecular bone loss; (c) a high level of individual variability, in which predicted age deviated from real age by as much as 22.26 (males) and 30.78 years (females); (d) a moderate linear correlation with age for all the variables analyzed; and (e) an average discrepancy between known age and predicted age (measured by root mean squared residual values) of 10.34 (males) and 12.71 years (females) for the most satisfactory DIP analysis parameter (recorded at the center of the femoral neck in the equalized images). With regard to estimating adult age at death from radiographic images of proximal femora, it is argued that the amount of useful age information reported for this criterion has been overestimated.

A clinical trial on the effects of a combination of elcatonin (carbocalcitonin) and conjugated estrogens on vertebral bone mass in early postmenopausal women

The study was carried out to determine the effect of a combination regimen of a small dose of calcitonin added to conjugated estrogens with medroxyprogesterone acetate on vertebral bone mass in early postmenopausal women. Comparisons were made with groups of women on calcitonin alone, on conjugated estrogens with medroxyprogesterone acetate alone, or on no treatment. The study was carried out over a 2-year period. The results of the study suggest that the combined regimen of calcitonin and estrogens increased vertebral bone mass in early postmenopausal women to a greater extent than calcitonin alone or estrogen alone. Increases in vertebral bone mass of 11.2% after 1 year and 9.2% after 2 years were demonstrated using the combined regimen. Both estrogens alone and calcitonin alone were, however, very effective in preventing rapid bone loss in the postmenopausal women studied.

Bone changes in postmenopausal Spanish women

Total body bone mass (TBBM), axial bone mass (trunk = chest and spine), and peripheral bone mass (arms and legs) were determined in 258 normal, slow bone mass loser, postmenopausal women, as determined by previous biochemical studies, in order to study the degree of bone mass reduction due to menopause. The subjects of this study were divided into 5-year groups on a year-since-menopause basis. The first group corresponded to 1-5 years since menopause, and the last group to 25 years or over since menopause. An important and significant reduction in trunk bone mass (-12.3%, P < 0.001) and TBBD (-5.8%, P < 0.002), without changes in head, arms, and legs was observed in the first 5-year group. In the next 5-year group, a significant reduction was observed in all body areas, but at a higher rate in the peripheral skeleton (-9% in arms and -7.3% in legs). A slow down in bone mass loss was observed in the period between 10 and 25 years since menopause. These values became significant again after 25 years since menopause at the axial (-28.9%, P < 0.001) and TBBD (-20.3%, P < 0.05) level. Aside from providing percentages of bone mass reduction with respect to age and time since menopause, these data also indicate that measurements of specific body areas may not be extrapolated to others due to different loss in different body areas, and that there is a marked bone loss rate in the axial skeleton in the first 5 years since menopause.

Effect of hormone replacement therapy and calcitonin on bone mass in postmenopausal women

A total of 104 postmenopausal women were randomly assigned to different therapeutic regimens: (a) calcitonin, (b) estrogen/progestogen (HRT) plus calcitonin, (c) estrogen/progestogen (HRT), (d) and the control group. The bone mass of the lumbar vertebrae of all patients was assessed with a dual beam photon absorptiometer (Norland GD 153). The 73 patients who completed the 1-yr study showed that postmenopausal bone loss could be prevented by either estrogen/progestogen (HRT) or calcitonin. In addition, the combination of hormonal replacement therapy and calcitonin not only prevented post-menopausal bone loss but resulted in a significant 10% gain in bone mass (P < 0.001).

Sex steroids and osteoporosis: effects of deficiencies and substitutive treatments

Adult mammalian bone is continuously renewed by the process of remodelling. In young healthy adults the amount of bone that is resorbed by osteoclasts is replaced by osteoblasts so that no net loss of bone occurs. In a situation of reduced sex hormone levels, such as in females after menopause or ovariectomy, in males after orchidectomy, or in patients of either sex with gonadal dysfunction, there is an imbalance between bone resorption and bone formation resulting in bone loss. The various hypotheses to explain the aetiology of this imbalance are reviewed. Substitution therapy of females with oestrogen results in the prevention of oestrogen deficiency-induced bone loss. It is generally agreed that the effect is due to inhibition of bone resorption. Recent in vitro data, however, indicate that oestrogens also have the capacity to stimulate the proliferation and functioning of bone-forming cells. Prevention of oestrogen deficiency-induced bone loss can also be achieved by treatment with high doses of progestagens. Available data suggest that this too is caused by resorption inhibition. The aim of treatment of females, who have lost so much bone that there is an increased risk of fractures after minimal trauma, is to increase bone mass rather than to prevent further bone loss. This can be accomplished by treatment with anabolic steroids. Both biochemical and histological data indicate that anabolics stimulate the activity of functioning osteoblasts. The increase in bone mass during continuous treatment is temporary because anabolics most probably also inhibit bone resorption. Substitution therapy with anabolics or androgens in males is equally effective and increases trabecular bone mass in the spine.

Decreasing rates of bone resorption in growing rats in vivo: comparison of different types of bones

This study quantifies rates of bone resorption by measuring the kinetic loss of 3H-tetracycline in vivo from the five different types of whole bones in four ages of normal male rats: appendicular bone (femur), cephalic bone (calvarium), axial bones (sixth lumbar vertebrae and sternum), and pelvis. The skeletons of newborn (0-2 weeks), weanling (4-7 weeks), adolescence (10-14 weeks), and mature (15-23 weeks) of Sprague Dawley rats were multiply labeled with 3H-tetracycline. The radioactivity in whole calvaria, the 6th lumbar vertebra, sternum, pelvis and femur was quantified to calculate the time course of tetracycline loss. The isotopic half lives (t1/2) were different for each age group and each bone, but the rates of resorption were usually the highest in the newborn rats. In the youngest animals, the t1/2 for the femur, vertebrae, and sternum was 1.5 week, for the pelvis it was 2.0 week, and for the calvarium it was 2.5 week. In the oldest age group, t1/2 for the femur was 28 week, for the calvarium was 19 week, for the sternum and pelvis was 16.5 week, and for the vertebrae was 13 week. For cephalic bones and femur, the greatest decrement in the rate of resorption occurred in the first 7 weeks of life (-52% and -72%, respectively). The axial bones and pelvis maintained a uniformly high resorptive rate until 7 weeks of age, which waned sharply at adolescence (-70% to -78%). At maturity the resorptive rate of these bones was less than 16% of the rate in the newborn.(ABSTRACT TRUNCATED AT 250 WORDS)

Hamann-Todd Collection aging studies: osteoporosis fracture syndrome

The study presents a retrospective analysis of distal radius, proximal femur, vertebral, and sacral fractures that occurred in 938 Hamann-Todd Collection skeletons. Individuals included in the investigation were retrieved from dissecting room cadavers in Cleveland, Ohio, between the years 1910 and 1940. Demographic analysis showed that the mean ages at death for blacks and whites included in the study were 41.9 and 53.8 years, respectively. Evaluations of fracture repair status were made for all fractures that were identified. Observations that document side of involvement and unilateral/bilateral distribution were made for distal radius and hip fractures. It was found that the age-, sex-, and race-related fracture patterns which characterize the early 20th century Hamann-Todd sample strongly correspond in distribution and magnitude to those seen in modern American and European urban industrial communities. The distal radius, hip, vertebral, and sacral fractures which were identified in individuals over 60 years of age appear to be a primary result of skeletal fragility due to age progressive bone loss. However, it is suggested that the early onset and high frequency of distal radius fractures seen in climacteric Caucasian women may be more directly due to accidental falls initiated by a greater frequency, intensity, and duration of vasomotor disturbances which are known to accompanay estrogen withdrawal in perimenopausal white females.

The proportion of trabecular bone in human vertebrae

The proportion of trabecular bone in human cadaver vertebrae was assessed by anatomic dissection. Thirty-two whole thoracic and lumbar vertebrae were obtained from 10 normal human postmenopausal female cadavers, 14 from 4 normal adult human male cadavers of similar age, and 8 from one female osteoporotic cadaver. Each vertebra was opened by saw cuts and separated into four tissue types: (1) body trabecular bone and marrow; (2) body cortical bone; (3) vertebral arch trabecular bone and marrow; and (4) vertebral arch cortical bone. Calcium was determined in each tissue type for each vertebra by ashing and atomic absorption spectrophotometry. Trabeculae accounted for 24.4 +/- 4.5% of the total calcium in whole female vertebrae, and 18.8 +/- 4.4% in whole male vertebrae (p less than 0.001). The body averaged 41.8% trabecular bone in females and 33.5% in males. The arch averaged 9.7% trabecular bone in females and 4.9% in males. The proportion of trabecular bone in the whole vertebrae in the single osteoporotic spine was 28.5 +/- 3.2%, a value not significantly different from the trabecular fraction in normal females. These data indicate that whole human thoraco-lumbar vertebrae are composed of a substantially lower proportion of trabecular bone than is usually assumed, and they suggest that cortical and trabecular bone are eventually lost in equal proportion from the vertebrae during the development of spinal osteoporosis. These results are important for the interpretation of data from noninvasive bone measurement techniques that evaluate the spine, and they suggest that studies of this type are important for any site where noninvasive bone mass measurement is done.

Postmenopausal estrogen and androgen replacement and lipoprotein lipid concentrations

The effect of a combined estrogen-androgen drug on the lipoprotein lipid profile of women who received it parenterally as long-term postmenopausal replacement therapy was compared to that of women who had been receiving estrogen alone parenterally and to untreated surgically menopausal women. Plasma estradiol, testosterone, total cholesterol, triglycerides, high-density lipoproteins, and low-density lipoproteins were measured at baseline (55 days after injection) and then on days 2, 4, 8, 15, 21, and 28 after injection. The plasma estradiol levels were greater in the two hormone-treated groups compared with the control group (p less than 0.01), and plasma testosterone levels of the combined group exceeded those of the other two groups (p less than 0.01) and remained above the normal female range for the duration of the study. There were no between-group differences in total cholesterol, triglycerides, high-density lipoprotein, or low-density lipoprotein values. Neither was the low-density/high-density lipoprotein ratio significantly different between groups at any of the test times. Therefore, the addition of testosterone to a long-term parenteral estrogen replacement regimen did not induce an increased atherogenic lipid profile compared with that produced by the parenteral administration of estrogen alone.

Women's attitudes toward the menopause: an update

A sample of 244 pre-, peri-, post-menopausal and hysterectomized women were administered a 10-item Menopause Attitude Questionnaire which assessed women's agreement with several controversial menopausal issues (i.e., whether the women subscribed to a view of menopause as a normal developmental stage or as a deficiency disease; attitudes toward hormonal replacement; and whether female sexuality was perceived as compromised during and subsequent to menopause). Results revealed that even a fairly homogeneous population of well-educated women held a considerable diversity of beliefs about the menopause. Respondents were clearly divided regarding the issue of hormone replacement therapy and its associated risks, but were united in holding optimistic beliefs about maintaining their femininity and sexuality subsequent to menopause. The implications of this research are discussed in terms of the current zeitgeist regarding menopause.