Menopause & Osteoporosis Flashcards
Definition of menopause?
No more menstrual periods for 1 year
Common symptoms of menopause?
- vasomotor sx (VMS): hot flashes
- genitourinary syndrome of menopause (GSM): dryness, UI, UTI etc
Types of HRT?
- estrogen only (for those without uterus)
- combi of estrogen & progesterone (for those with uterus): either both continuous or continuous (E) -cyclic (P)
- tibolone
Will VSM and GSM improve over time?
VSM yes, GSM no
Topical options for VMS?
- Premarin (estrogen) cream
- vagifem (estrogen) tablet for vaginal insert
- lubricants, moisturisers
Possible supplements for menopause?
- isoflavones (soy)
- black cohosh
- evening primrose oil
- vitamin E
Is progestin-only HRT recommended?
Possible but no long term studies
Which progesterone is natural?
utrogestan (micronised progesterone)
Advantage of systemic topicals compared to PO?
Bypass hepatic 1st pass effect
Can tibolone be used in women with uterus? Need additional progesterone?
Yes, no need progesterone as tibolone sufficiently suppresses endometrial proliferation & estrogen activation
Can tibolone protect against bone loss?
Yes
Non-hormonal therapy for VMS?
- SSRI: paroxetine, escitalopram
- SNRI: venlafaxine
- gabapentin, pregabalin
- clonidine
BMD t-score cut-offs?
- normal
- osteopenia
- osteoporosis
- normal: ≥-1
- osteopenia: -2.5<x<-1
- osteoporosis: ≤-2.5
Pathophysiology of osteoporosis?
osteoclastic >osteoblastic
How does menopause cause osteoporosis?
reduce estrogen -> more bone resorption, more Ca excretion
Meds a/w osteoporosis?
glucocorticoids, PPI, immunosuppressants, ASM
What tool to use to screen post-menopausal women for osteoporosis?
Scores for high, medium and low risk and follow-up actions?
osteoporosis self-assessment tool for asians
- low: <0, can defer DXA
- medium: 0-20, consider DXA if have other risk factors
- high: >20, consider DXA
What height loss is considered a risk factor for osteoporosis?
> 2cm within 3y
How to calculate 10 year probability of having fracture? What is the threshold for major osteoporotic fracture and hip fracture?
FRAX score
- major osteoporotic fracture ≥20%
- hip fracture ≥3%
Vitamin D intake requirements for:
- 51-70y
- >70y
- 51-70y: 600 IU/day
- > 70y: 800 IU/day
What Z-score suggests that osteoporosis is due to secondary causes?
≤ -2
How to diagnose osteoporosis?
either one
- history of fragility fracture
- BMD measurement using DXA hip +/ spine (T score ≤ -2.5)
When to start treatment for osteoporosis?
- fragility fracture
- no fragility fracture but BMD ≤ -2.5
- osteopenic with high fracture risk (FRAX ≥3% hip or ≥20% major osteoporotic fracture)
Calcium intake requirements per day? Maximum calcium absorption per dose?
800-1000mg
Body can absorb 500mg max, give in divided doses if more than that per dose
Nonpharm for osteoporosis?
- exercise (weight bearing, muscle strengthening)
- smoking cessation
- reduce alcohol, caffeine
- eat more calcium rich foods
- fall prevention
Possible treatment options for osteoporosis?
antiresorptive
- bisphosphonates
- denosumab (RANK ligand inhibitor)
- raloxifene (estrogen agonist/antagonist)
- calcitonin
anabolic
- teriparatide (PTH analog)
- romosozumab (sclerostin inhibitor)
Calcium percentage content?
- calcium carbonate
- calcium citrate
- calcium acetate
- calcium carbonate: 40%
- calcium citrate: 21%
- calcium acetate: 25%
Is vitamin D water or fat soluble?
Fat soluble
Available bisphosphonates and dose?
- alendronate (PO): 70mg Q1w or 10mg OD
- risedronate (PO): 35mg Q1w or 150mg Q1m
- zoledronic acid (IV): 5mg Q1y as 15min IV infusion
Counselling points for PO bisphosphonates? (4)
- take on empty stomach with full glass of PLAIN water (no mineral water -> affect absorption)
- wait ≥30min before taking food
- space apart from other meds ≥2h
- do not lie down after taking med, stay upright for ≥30min
Duration of treatment for PO and IV bisphosphonates, and denosumab? Max duration?
PO: 5y (max 10y)
IV: 3y (max 6y)
Denosumab: up to 10y
Rare but serious SE of bisphosphonates?
- atypical femoral fractures (thigh, groin)
- osteonecrosis of the jaw
CrCl cut off for bisphosphonates?
- <30 for risedronate
- <35 for alendronate & zoledronic acid
Common SE of bisphosphonates?
- GI: flatulence, heartburn, N/D, abd pain
- HA, MSK pain, rash
- hypoCa (transient)
- IV: flu-like sx
MOA of:
- bisphosphonates
- denosumab
- raloxifene
- calcitonin
- romosozumab
- PTH
- bisphosphonates: increase osteoclast death
- denosumab: prevent osteoclast development (RANKL inhibitor)
- raloxifene: selective estrogen receptor modulator (reduce resorption)
- calcitonin: inhibit osteoclast activity
- romosozumab: inhibit sclerostin -> anabolic & antiresorptive
- PTH: stimulate osteoblast activity
Dosing regimen of denosumab? What else should be given to patient while on denosumab?
SC 60mg Q6m, give Ca & vit D
Difference between calcium carbonate and calcium citrate?
calcium carbonate must be taken with food, calcium citrate can be taken regardless of food
