The menopause and HRT. Prevention and management of osteoporosis

The Heterogeneity of Post-Menopausal Disease Risk: Could the Basis for Why Only Subsets of Females Are Affected Be Due to a Reversible Epigenetic Modification System Associated with Puberty, Menstrual Cycles, Pregnancy and Lactation, and, Ultimately, Menopause?

For much of human evolution, the average lifespan was <40 years, due in part to disease, infant mortality, predators, food insecurity, and, for females, complications of childbirth. Thus, for much of evolution, many females did not reach the age of menopause (45-50 years of age) and it is mainly in the past several hundred years that the lifespan has been extended to >75 years, primarily due to public health advances, medical interventions, antibiotics, and nutrition. Therefore, the underlying biological mechanisms responsible for disease risk following menopause must have evolved during the complex processes leading to Homo sapiens to serve functions in the pre-menopausal state. Furthermore, as a primary function for the survival of the species is effective reproduction, it is likely that most of the advantages of having such post-menopausal risks relate to reproduction and the ability to address environmental stresses. This opinion/perspective will be discussed in the context of how such post-menopausal risks could enhance reproduction, with improved survival of offspring, and perhaps why such risks are preserved. Not all post-menopausal females exhibit risk for this set of diseases, and those who do develop such diseases do not have all of the conditions. The diseases of the post-menopausal state do not operate as a unified complex, but as independent variables, with the potential for some overlap. The how and why there would be such heterogeneity if the risk factors serve essential functions during the reproductive years is also discussed and the concept of sets of reversible epigenetic changes associated with puberty, pregnancy, and lactation is offered to explain the observations regarding the distribution of post-menopausal conditions and their potential roles in reproduction. While the involvement of an epigenetic system with a dynamic "modification-demodification-remodification" paradigm contributing to disease risk is a hypothesis at this point, validation of it could lead to a better understanding of post-menopausal disease risk in the context of reproduction with commonalities may also lead to future improved interventions to control such risk after menopause.

Correlation of Hounsfield Units with Bone Mineral Density and T-Score in Chinese Adults

OBJECTIVE

To examine the association between vertebral cancellous Hounsfield units (HUs), age, bone mineral density, and T-score in a sample of Chinese adults.

METHODS

The study included a sample of 739 participants. Age, bone mineral density, and T-score of each participant were recorded, and HUs were measured in the L1-L4 vertebrae.

RESULTS

Data analysis revealed that HUs of vertebral cancellous bone across the pedicle level decreased with age, with women having higher values than men up to age 50 and vice versa thereafter. Furthermore, a positive correlation was found between HUs of vertebral cancellous bone across the pedicle level and bone mineral density/T-score in the L1-L4 vertebrae, but with a weaker correlation in the L4 vertebrae. Additionally, HU values for participants with osteoporosis were significantly lower than HU values for participants with osteopenia and normal bone health.

CONCLUSIONS

From the findings of this study, it can be concluded that HUs may be a potential predictor of bone health, with implications for presurgical assessment of the quality of bone-screw interfaces for spinal surgery.

Promoting osteointegration effect of Cu alloyed titanium (TiCu) in ovariectomized rats

Osteoporosis is a common skeletal disease making patients be prone to the osteoporotic fracture. However, the clinical implants made of titanium and its alloys with a poor osseointegration need a long time for healing and easily to loosening. Thus, a new class of Cu-alloyed titanium (TiCu) alloys with excellent mechanical properties and bio-functionalization has been developed. In this study, the osteoporosis modeled rats were used to study the osteointegration effect and underlying mechanism of TiCu. The results showed that after implantation for 4 weeks, TiCu alloy could promote the reconstruction of vascular network around the implant by up-regulating vascular endothelial growth factor expression. After 8 weeks, it could further promote the proliferation and differentiation of osteoblasts, mineralization and deposition of collagens, and then significantly increasing bone mineral density around the implant. In conclusion, TiCu alloy would enhance the fixation stability, accelerate the osteointegration, and thus reduce the risk of aseptic loosening during the long-term implantation in the osteoporosis environment. This study was the first to report the role and mechanism of a Cu-alloyed metal in promoting osteointegration in osteoporosis environment, which provides a new attractive support for the improvement of future clinical applications of Cu-alloyed antibacterial titanium alloys.

The Effect of Kinesitherapy on Bone Mineral Density in Primary Osteoporosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

Objective

Osteoporosis (OP) is a well-established age-related disease, pathologically characterized by bone microarchitectural deterioration, increased fragility, and low BMD. Primary osteoporosis (POP) is the most common type of OP.

Methods

Publications pertaining to the effectiveness of kinesitherapy on BMD in POP from PubMed, SCI, Cochrane Library, Embase, VIP, CNKI, and Wanfang Database were retrieved from their inception to October 2019.

Results

A total of 21 studies with 1840 participants were included. The results of the meta-analysis revealed that kinesitherapy plus antiosteoporosis medications had a positive effect on lumbar spine BMD when the duration of intervention was 6 months (MD = 0.11 g/cm²; 95% CI: 0.06–0.15; P < 0.0001) or >6 months (MD = 0.04 g/cm²; 95% CI: 0.02–0.06; P < 0.0001) compared with antiosteoporosis medications alone. Additional kinesitherapy plus antiosteoporosis medications were associated with improved femoral neck BMD compared with antiosteoporosis medications alone (MD = 0.09 g/cm²; 95% CI: 0.03–0.16; P=0.004).

Conclusions

Kinesitherapy plus antiosteoporosis medications significantly improved lumbar spine and femoral neck BMD in the current low-quality evidence. Additional high-quality evidence is required to confirm the effect of kinesitherapy on BMD in patients with POP.

Can Vitamin D supplementation alone effective to increase a physical fitness levels in post-menopausal women with metabolic disorders? Brief Review

BACKGROUND

During the climacteric period, occur an aging process of the skin, and promote several decreases in the ability of vitamin D synthesis in an organism and lower levels of Vitamin D may contribute to the appearance of conditions such as osteomalacia, osteoporosis, falls and fractures.

AIM

The present brief review focuses on the influence of Vitamin D supplementation alone on physical fitness (strength, endurance, and balance) in postmenopausal with diseases or not.

METHODS

Search in Medline and PubMed relevant articles with Vitamin D supplementation alone on physical fitness (strength, endurance, and balance) in postmenopausal with diseases or not, were included only 5 clinical.

CONCLUSIONS

In conclusion, the effectiveness depends on the amount was prescribed for supplementation and the patient's characteristics. Doses less than 1000 IU/d did not show significant changes in physical fitness on post-menopausal women with metabolic diseases or not.

Association of collagen type I alpha 1 +1245G/T polymorphism and osteoporosis risk in post-menopausal women: a meta-analysis

AIM

To fully understand the association between collagen type I alpha 1 (COL1A1) +1245G/T polymorphism and osteoporosis risk in post-menopausal women.

METHODS

We searched the electronic databases including PubMed, Embase and Cochrane library updated to January 2016, as well as printed articles. Studies were screened according to the predefined inclusion and exclusion criteria, and the included studies were further assessed by Clark scores system. Furthermore, the association between COL1A1 +1245G/T polymorphism and osteoporosis risk was assessed using odds ratios (ORs) and their 95% confidence intervals (95% CIs). Additionally, the meta-analysis was carried out using Review Manger 5.1 software (Cochrane Collaboration, Oxford, UK) and Stata 11.0 software (StataCorp, College Station, TX, USA).

RESULTS

A total of five studies, which contained 1557 subjects (including 458 osteoporosis patients, 269 osteopenic patients and 830 normal controls), were included. Further, the included studies achieved Clark scores no less than 5, indicating a moderate or high quality. The pooled effect size indicated that there was a significant association between COL1A1 +1245G/T polymorphism and osteoporosis risk only under a co-dominant model (GG vs. TT, OR = 2.45, 95% CI = 1.11-5.44, P = 0.03). Moreover, there was no significant correlation between COL1A1 +1245G/T polymorphism and osteopenic risk under each model (P > 0.05).

CONCLUSION

There might be a certain relationship between GG genotype of COL1A1 +1245G/T polymorphism and osteoporosis risk in post-menopausal women.

Serum carcinoembryonic antigen-related cell adhesion molecule 1 level in postmenopausal women: correlation with β-catenin and bone mineral density

Many epidemiological studies have shown that in some tumors carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) and β-catenin appear to be related. However, it remains to be established whether CEACAM1 is related to β-catenin in osteoporosis. Here, we reveal that CEACAM1 might influence the canonical Wnt/β-catenin pathway to modulate bone metabolism in postmenopausal osteoporosis.

INTRODUCTION

The aim of this study is to assess the serum level of CEACAM1 in postmenopausal women and its correlation with β-catenin and bone mineral density (BMD).

METHODS

The BMD was measured at the lumbar spine (L1-L4) or the femoral neck using dual-energy X-ray absorptiometry (DXA). Serum CEACAM1, β-catenin, receptor activator of nuclear factor kappa-B (RANKL), osteoprotegerin (OPG), β-isomerized C-terminal crosslinking of type I collagen (β-CTX), intact N-terminal propeptide of type I collagen (PINP), estradiol, and insulin were measured in 350 postmenopausal women. Patients were divided according to lumbar spine or femur neck T-scores into osteoporosis (group I), osteopenia (group II), and normal bone mineral density, the latter serving as control.

RESULTS

Serum CEACAM1 levels were significantly lower in group I and II compared to those in control subjects (P < 0.001). Serum CEACAM1 levels correlated positively with β-catenin and BMD, but correlated negatively to the ratio between RANKL and OPG.

CONCLUSION

This study provides evidence that decreased serum CEACAM1 levels are related to low BMD in postmenopausal women, and that serum CEACAM1 levels correlated positively to β-catenin. It suggests that CEACAM1 might influence the canonical Wnt/β-catenin pathway to modulate bone metabolism.

In vivo estrogenic-like activities of Gouania longipetala Hemsl. (Rhamnaceae) bark extracts in a post-menopause-like model of ovariectomized Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

Gouania longipetala is commonly used in Cameroonian traditional medicine to manage women fertility and menopausal complaints. However, despite this use, the estrogenic properties of G. longipetala have not been studied until now.

AIM OF STUDY

The present study was aimed to assess estrogenic activities of the stem bark aqueous (GLA) and ethanolic (GLE) extracts of G. longipetala in post-menopause-like model of ovariectomized (Ovx) Wistar rats.

MATERIAL AND METHODS

Animals were either sham-operated or Ovx. 84 days after ovariectomy, animals were divided into seven groups of five animals and were daily treated for 28 days with distilled water (10 mL/kg) for group 1, 2% solution of Tween 80 (10 mL/kg) for group 2, estradiol valerate (1 mg/kg) for group 3, GLA (45 or 180 mg/kg) and GLE (40 or 160 mg/kg) for groups 4 to 7 respectively. Sham-operated animals daily received distilled water (10 mL/kg). During the experimental period, the body weight was registered every week. At the day 29, blood pressure was registered by invasive method while uterine and vagina morphometry as well as body, uterine and abdominal fat weights changes were analyzed. Serum levels of total cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol were determined. Moreover, oxidative stress markers such as nitrites, reduced glutathione (GSH) and malondialdehyde (MDA) were measured in homogenized liver and aorta.

RESULTS

Compared with the sham control, vagina and uterine dystrophy and elevated blood pressure were observed in Ovx rats treated with vehicles. Biochemical parameters showed a significant increase of total cholesterol, triglycerides, LDL-cholesterol and MDA as well as a significant decrease of nitrites and GSH in Ovx animals treated with vehicle as compared to sham group. GLA and GLE displayed estrogen-like effects on vagina and did not affect uterine wet weight and epithelial height compared with vehicle groups. Both extracts displayed anti-atherogenic properties by reducing AI, AIP and LDL-cholesterol level as compared to vehicles groups. GLA and GLE significantly prevented the increase of MDA induced by ovariectomy as compared to rats treated with vehicles.

CONCLUSION

This study showed that GLA and GLE exhibited estrogenic effects by providing vaginal lubrication, by modulating blood pressure and improving lipid profile, oxidative status and endothelial function and may not have an undesirable influence on the endometrium in ovariectomized rats.

Cost-utility of denosumab for the treatment of postmenopausal osteoporosis in Spain

BACKGROUND

The objective of this study was to estimate the cost-effectiveness of denosumab for fracture prevention compared with no treatment, generic bisphosphonates, and strontium ranelate in a cohort of osteoporotic postmenopausal women in Spain.

METHODS

A Markov model represented the possible health state transitions of Spanish postmenopausal women from initiation of fracture prevention treatment until age 100 years or death. The perspective was that of the Spanish National Health System. Fracture efficacy data for denosumab were taken from a randomized controlled trial. Fracture efficacy data for alendronate, ibandronate, risedronate, and strontium ranelate were taken from an independent meta-analysis. Data on the incidence of fractures in Spain were either taken from the published literature or derived from Swedish data after applying a correction factor based on the reported incidence from each country. Resource use in each health state was obtained from the literature, or where no data had been published, conservative assumptions were made. Utility values for the various fracture health states were taken from published sources. The primary endpoints of the model were life-years gained, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios for denosumab against the comparators.

RESULTS

Denosumab reduced the risk of fractures compared with either no treatment or the other active interventions, and produced the greatest gains in life-years and QALYs. With an annual acquisition cost of €417.34 for denosumab, the incremental cost-effectiveness ratios for denosumab versus no treatment, alendronate, risedronate, and ibandronate were estimated at €6,823, €16,294, €4,895, and €2,205 per QALY gained, respectively. Denosumab dominated strontium ranelate. Sensitivity analyses confirmed the robustness of these findings.

CONCLUSION

Our analyses show that denosumab is a cost-effective intervention for fracture prevention in osteoporotic postmenopausal women in Spain compared with alendronate and risedronate, and is a dominant treatment option compared with strontium ranelate.

Estrogen receptor alpha-mediated adiposity-lowering and hypocholesterolemic actions of the selective estrogen receptor modulator acolbifene

OBJECTIVE

The selective estrogen receptor (ER) modulator (SERM) acolbifene (ACOL), a potent and pure antiestrogen in the mammary gland and uterus, exerts beneficial pro-estrogenic actions on energy balance, insulin sensitivity and lipid metabolism. ACOL binds ERs alpha and beta, both of which have been involved in the metabolic actions of estrogen. This study aimed at determining the identity of the ER involved in the beneficial metabolic actions of ACOL.

DESIGN AND MEASUREMENTS

ACOL was administered for 4 weeks to male and female wild-type and ERalpha knockout (KO) mice, and indices of energy balance as well as plasma and liver lipid concentrations were determined.

RESULTS

ERalpha KO mice were heavier, gained more fat mass and had larger adipose depots than their wild-type counterparts. In both genders, ACOL decreased fat gain (50%) and white adipose tissue mass in male and female wild-type, but not in ERalpha KO mice. ACOL reduced plasma cholesterol in female wild-type mice (-27%), whereas the compound remained ineffective in their ERalpha KO counterparts. Plasma triglycerides were unaffected by ACOL. Finally, ACOL decreased liver cholesterol and triglyceride concentrations only in wild-type female animals.

CONCLUSION

The beneficial metabolic actions of the SERM ACOL on adiposity and on plasma and liver lipids are entirely due to its interaction with the ERalpha.

Available medical choices for the management of menopause

The age at which menopause occurs is a critical factor in the magnitude of its consequences. Most of the medium-to-long-term effects of oestrogen deprivation depend on their duration. The timing of the last menstruation is therefore important, but hypoestrogenic amenorrhoea during the reproductive age is also a relevant factor in the evaluation of individual risks. In recent years, moving post-menopausal women from the lowest point of ovarian hypofunction has been the most important motivation for developing guidelines for the hormonal management of menopause. However, recent data suggest that this may be associated with an unacceptable increase in morbidity in a number of women. Concerns about long-term hormone replacement therapy (HRT) at menopause have recently enhanced interest in a group of molecules that act on the oestrogen receptor with selective effects, known as selective oestrogen receptor modulators (SERMs). Of these, Raloxifene has been approved for the treatment and prevention of osteoporosis, and exhibits a pattern of actions particularly well matched to the needs and concerns of post-menopausal women. Further studies on SERMs may open up new vistas in patient-specific management of post-menopausal health. Finally, debates on the specific health consequences of menopause deal mainly with the risk of chronic disease. Gynaecologists and other health professionals would be advised to develop intervention strategies at menopause according to the continuum of a woman's life, beginning at the post-menarche and extending into later life.

The Role of Calcium in Osteoporosis Drug Therapy

Great advances have been made in the field of osteoporosis treatment and prevention in recent years that have led to the availability of powerful new drugs. These drugs are viewed by patients and physicians as a major breakthrough in the management of osteoporosis. Unfortunately, this view has led many to ignore the importance of concurrent calcium supplementation to ensure the maximum benefit from these drugs, as evidenced by the recent decline in use of calcium supplements. As the majority of patients fail to consume the minimum recommended dietary intake of calcium, it is critical to recommend calcium supplements to raise total daily calcium intake to the levels needed to ensure maximum efficacy of osteoporosis treatments. Furthermore, osteoporosis drug labeling should be strengthened to encourage proper use of these drugs in combination with calcium supplements.

Once-Monthly Ibandronate

Ibandronate is a nitrogen-containing bisphosphonate that has been approved for once-monthly administration in women with post-menopausal osteoporosis. Animal data suggest that the efficacy of the drug is determined by the cumulative dose rather than the frequency of administration. After treatment for 1 year in a large, randomized, double-blind, multicenter trial in women with postmenopausal osteoporosis, once-monthly ibandronate 150 mg was non-inferior to once-daily ibandronate 2.5 mg in terms of increases in mean lumbar spine (primary endpoint) and hip bone mineral density (BMD). In addition, once-monthly ibandronate 150 mg was significantly more effective than once-daily ibandronate for mean increase from baseline in lumbar spine BMD after 1 and 2 years. In another large, randomized, double-blind trial in women with osteoporosis, both once-daily and intermittent (>2-month between-dose interval [not approved]) ibandronate were significantly more effective than placebo in reducing the risk of new vertebral fractures, after treatment for 3 years. Once-daily and intermittent ibandronate also increased mean lumbar spine and hip BMD from baseline by significantly more than placebo. Oral once-monthly, once-daily, and intermittent ibandronate were generally well tolerated. Monthly ibandronate had a similar tolerability profile to once-daily ibandronate. The incidence of adverse events, including gastrointestinal events, with once-daily and intermittent ibandronate did not differ significantly from that with placebo. Significantly more women with osteoporosis preferred once-monthly ibandronate and found it more convenient than once-weekly alendronate, according to data from a 6-month, randomized, open-label, crossover study.