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Postmenopausal osteoporosis: a scenario for hormones?

The decrease in bone density and the development of osteoporosis often represent a significant challenge in the clinical context of our day-to-day office life. Postmenopausal women face a series of symptoms associated with climacteric and menopause, which lead them to seek medical attention. However, due to its often asymptomatic nature, bone loss is not usually the most common complaint. For this reason, it is crucial to pay special attention to this issue during the medical consultation.

In medical care for postmenopausal women, it is essential that you are able to manage and prevent the decrease in bone density. This requires an in-depth understanding of the pathophysiology of aging, as well as the metabolic and hormonal changes that occur during this period. As women face the challenges of climacteric and menopause, it is important for healthcare professionals to be aware that osteoporosis, although often silent, is a significant concern that deserves special attention during the doctor's visit.



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What is osteoporosis?

Osteoporosis is a disease characterized by low bone density and structural deterioration of bone tissue, which results in bone fragility. Bone mass is commonly measured through bone mineral content and areal or volumetric bone mineral density using dual-energy X-ray absorptiometry (DXA). Operationally, osteoporosis is usually defined as having a bone mineral density at or below 2.5 standard deviations of the mean value observed in young, healthy women.

Bone mass in the aging phase is proportional to the density achieved during the growth phase and the rate of loss. Several studies suggest that a woman's peak bone density in adulthood has a greater impact on bone composition than the marked loss in the first 15 years after menopause. That is, a 10% increase in peak bone mass could potentially reduce the risk of osteoporotic fractures in older adults by 50%. Therefore, achieving and maintaining high peak bone mass during the first three decades of life offers a promising prospect for preventing osteoporosis.

The accumulation of minerals in bones, from childhood to post-puberty, is a complex process. In general, maximum bone mass achieved is greater in men than in women and in African Americans compared to non-Hispanic whites. Several interconnected and modifiable factors influence the accumulation of bone mass, such as nutrition, physical activity, hormonal environment and smoking. These factors may account for 20-50% of this variation.


Osteoporosis and postmenopause in Literature

In this sense, data published in the study Peak Bone Mass and Patterns of Change in Total Bone Mineral Density and Bone Mineral Contents From Childhood Into Young Adulthood,in April 2016 , in theJournal of Clinical Densitometry: the official journal of international society for clinical densitometry,showed evidence that indicates Hormone Replacement Therapy can play a significant role in preserving our patient's bone health.

Certainly, considering the possibility of starting hormonal treatments, especially in the early stages of menopause, is an approach that deserves attention. Choosing the most appropriate form of hormone replacement can be decisive in increasing the chances of success in maintaining bone health. Furthermore, it contributes to a better quality of life for women at this stage of life. 


Future of osteoporosis

However, the most recent published guidelines not only highlight the relevance of understanding how and when to prescribe Hormone Replacement Therapy (HRT), but also emphasize the importance of adequate duration of treatment. In these circumstances, personalization and adaptation of monitoring according to the patient's individual needs are crucial to ensure a satisfactory clinical evolution.

The study also demonstrates that bone mineral density has a tendency to follow a stable trajectory from childhood to early adulthood. Therefore, children with low BMD are likely to maintain that low BMD unless effective interventions are implemented. Furthermore, girls who reach puberty late tend to accumulate less bone mineral content compared to their peers who mature early or averagely. 

The results of this study suggest that achieving high bone mass initially predicts higher BMD and a lower risk of osteoporosis. Furthermore, the analysis reveals a significant positive correlation between maximum BMD until adulthood and BMD during aging.


Clinical Practice

In summary, it is crucial to recognize that modifiable factors play a fundamental role in bone health and must be implemented broadly across the population that attends your practice. It's not just a single action, but rather an ongoing commitment to strengthening bones and muscles from an early age to reap the benefits and achieve healthy performance in the future.

Finally, Hormone Replacement Therapy stands out as a superior treatment option compared to other medications for maintaining and stimulating bone matrix. Recent studies and consensus have contributed to demystifying the idea of a maximum time limit for the use of HRT, which was previously 10 years. Or any other myth about the relationship between the use of female hormones and breast cancer, of course based on each patient's personal history.

Currently, women have the flexibility to decide how long they want to use hormones in the postmenopausal phase, as long as this is done under the careful supervision of an endocrinologist. This personalized approach opens up new possibilities for promoting bone health and well-being in women as they age.


References

LU, J. et al. Peak Bone Mass and Patterns of Change in Total Bone Mineral Density and Bone Mineral Contents From Childhood Into Young Adulthood. Journal of Clinical Densitometry, vol. 19, no. 2, p. 180–191, apr. 2016. 

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