Menopause and Osteoporosis Flashcards
typical age for menopause
45-55 years
Age for early menopause
40-45 years
If your patient is going through menopause and they are under 40 you should work them up for
ovarian disorder → primary ovarian insufficiency
what causes surgical menopause?
removal of ovaries surgically
How long must a woman have amenorrhea to be considered menopausal?
1 year
what will lab values be for a patient in menopause?
elevated FSH and low estradiol
consider TSH, HCG, prolactin
period where you transition from reproductive to non-reproductive years
perimenopause
what is the average duration of perimenopause? How many years before menopause does it occur?
4 years
5-10 years prior
How will cycle change in the perimenopause phase?
cycle may be shorter → shortened follicular phase
cycle may be longer → anovulation
What is the difference between perimenopause and menopause?
perimenopause is irregular menses and menopause is absence of menses
80% of women experience ___ with menopause
vasomotor symptoms
Symptoms associated with menopause
mood disturbances (anxiety, depression, irritable), sleep disturbance, poor concentration, heart palpitations, decreased interest/painful sex, drying/atrophy of vagina, infertility, fatigue, headache, tension, feelings of inadequacy or nonfulfillment
Two biggest effects of menopause
increased risk of CVD and increased risk for osteoporosis
Other effects of menopause
stress incontinence, loss of skin reilience and pliability, dry hair or loss, dry mouth, lower voice, easily traumatized skin, weight gain (truncal), osteoporosis
What are the treatment goals of managing menopause?
relieve symptoms
in which patients is HRT appropriate in treating postmenopausal women?
< 60 years, < 10 years out from onset of menopause, moderate to severe symptoms
Treatment for women with intact uterus to prevent endometrial hyperplasia
estrogen + progesterone
What type of HRT is preferred in women with moderate risk of CVD (decreases risk of thromboembolism)?
transdermal
What HRT method is preferred in women with genitourinary symptoms?
intravaginal
why are bioidentical hormone therapy preparations not recommended?
higher rates of adverse effects and lack of long term safety data
Contraindications for HRT
unexplained vaginal bleeding, thrombophilia, breast or endometrial cancer, arterila thromboembolic disease (stroke, TIA, MI, PE, DVT), liver disease, anaphylactic reaction, pregnancy
Benefits of HRT in menopause
reduced risk for hip fracture
reduced risk of colorectal cancer
reduced breast cancer risk (estrogen only HRT)
alternative to estrogen replacement for women at risk for osteoporosis who cannot or prefer not to take estrogen
Selective Estroen Receptor Modulators (SERMs)
Nonhormonal therapies for menopause
SSRI, SNRI, gabapentin, pregabalin
systemic skeletal disease involving low bone mass and micro architectual deterioration of bone tissue → increased bone fragility and increased fracture risk
osteoporosis
How is osteoporosis diagnosed?
based on history of fragility fracture or BMD criteria
fracture that occurs after an injury that wouldn’t have expected to result in a fractured bone
fragility fractures
common sites of fragility fractures
hip, vertebrae, wrist
DEXA definition of osteoporosis
BMD 2.5 standard deviations below young adult mean for women
Most common form of osteoporosis
postmenopausal
Where does DEXA take measurements - gold standard?
femoral neck or spine
Normal BMD has T-score
higher than -1.0
Low BMD (osteopenia) has T-score
between -1.0 and -2.5
Osteoporosis has T-score
lower than -2.5
Alternative method to DEXA in testing bone density?
quantitative ultrasound of calcaneous (QUS) → good at predicting risk but unclear on how useful in selecting medication
who should get DEXA scan?
women >65 and men >70
young post menopausal women w/ risk factors
bone break after age 50
what are some osteoporosis risk factors?
age, long term PPI therapy, low body weight, hypogonadism (men)
“ACCESS” risk factors of osteoporosis
alcohol use, corticosteroids, calcium (low), estrogen (low), smoking, sedementary lifestyle
Meds that can cause osteoporosis
depo provera (contraceptive), PPI, SSRI, glucocorticoids, tamoxifen, thyroid hormones
autoimmune disorders that increase risk of osteoporosis
RA, Lupus, MS, ankylosing spondylitis
medical procedures that may increase risk of osteoporosis
gastrectomy, GI bypass
hematologic/blood disorders that may increase risk of osteoporosis
leukemia and lymphoma, multiple myeloma, sickle cell disease, thalassemia
digestive and GI disorders that may increase risk of osteoporosis
Celiac, IBD, weight loss surgery
Cancers that may increase risk of osteoporosis
breast and prostate
Neuro disorders that increase the risk of osteoporosis
stroke, Parkinson, MS, spinal cord injuries
Endocrine/hormonal disorders that increases the risk of osteoporosis
diabetes, hyperparathyroidism, hyperthyroidism, Cushings, thyrotoxins, irregular periods, premature menopause
risk factors for fragility fractures
smoking, excessive alcohol, physical inactivity, poor nutrition
computer based risk assessment tool to estimate 10 year probability of hip fractures and other major fractures for untreated patients 40-90 years old
FRAX
What are some labs you’d want to order in working up a fragility fracture?
biochemistry profile (Ca, P, albumin, total protein, creatinine, Alkaline phosphatase, electrolytes)
25 hydroxyvitamin D
CBC
BMP
Calcium and Vitamin D recommendations to prevent osteoporosis
1,200mg/day calcium
800 - 1,000 IU Vitamin D
What are some calcium rich foods?
milk and dairy, leafy green vegetables, okra, sardines, soybreans/tofu, white beans, almonds
Which patients should you consider osteoporosis treatment in?
T-score between -1 and -2.5
FRAX >3% or >20%
Before initiating any osteoporosis treatment, what lab values must be normal and what must the patient be taking?
normal serum Ca and 25-hydroxyvitamin D
dietary supplements
First line treatemnt for osteoporosis
PO bisphosphonates
Biggest adverse effect of bisphosponates
upper GI irritation
Other methods of treating/preventing osteoporosis - not first line
SERM, HRT, forteo, IV Zoledronic acid
What do you consider when choosing a bisphosphonate?
preference, convenience, dosing schedule, cost
Which bisphosphonate do you have to administer weekly? Which do you get once a year?
alendronate
zoledronic acid
Side effects of oral bisphosphonates and how can you prevent?
stomach upset and heartburn → take with full glass of water on empty staomch and sit up for 30-60min after
IV form of bisphosphonates cause what side effects
flu like symptoms
second line for people who cannot take bisphosphonates
denosumbab
Two second line therapies that can rebuild bone in osteoporosis
teriparatide and abaloparatide
