Osteoporosis

Oestrogens regulate the balance between the breakdown of bone, “bone resorption” and bone formation. Declining Oestrogen levels due to the Menopause results in reduced bone density.

Women never reach the same peak bone mass as men but during the menopausal transition, there is increased bone turnover resulting in a lower bone density and a lower threshold for fracture.

1 in 2 women will get an Osteoporotic fracture. This compares to 1 in 4 men. 90% of hip fractures are due to osteoporosis. Osteoporosis generally does not cause any symptoms until a fracture occurs. Certain patient groups are at higher risk of developing Osteoporosis and fracture:

1. Early or premature menopause
2. Very low BMI
3. Smokers
4. Sedentary lifestyle / reduce mobility
5. Coeliac disease or other causes of malabsorption
6. Overactive parathyroid and parathyroid disease
7. Long term use of steroids
8. Family history of osteoporosis
9. History of Rheumatoid arthritis or other inflammatory bone diseases
10. Age
11. Vitamin D deficiency /poor diet
12. High alcohol intake
13. Previous history of fracture
14. Previous history of fall
15. Osteopenia* on DEXA scan

*Osteopenia means reduced bone density resulting in increased risk of developing osteoporosis & fractures.

For people at increased risk of osteoporosis, a DEXA scan will be organised. The DEXA will establish the presence of Osteopenia or Osteoporosis but it should not be used on its own in deciding treatment options. It is important to establish the fracture risk either by SCORE or FRAX; the ultimate goal is to prevent fractures and reduce mortality and morbidity.

Diagnosis

1. T-score of -2.5 or less at hip or spine on DEXA
2. Low impact fracture
3. FRAX score 10 year risk of hip fracture > 3 % , or risk of major Osteoporotic fracture with Osteopenia > 20 %

It is very important to look after your bones no matter what age you are. A good calcium intake such as the regular consumption of milk, cheese and yogurts, adequate vitamin D levels, maintaining a healthy weight and exercising ( including weight bearing and resistance training ) will significantly improve bone health.

Hormone Replacement Therapy (HRT)

HRT has been proven to reduce the risk of spinal and hip osteoporosis and all osteoporosis- associated fractures. HRT is the only treatment of proven efficacy in reducing fractures in patients with Osteopenia.

Types of HRT

There are more than 50 types of HRT and they can be given in various forms – orally (tablets), transdermally (through the skin); subcutaneously (a long-lasting implant); or vaginally.

• Cyclical HRT mimics the normal menstrual cycle. Oestrogen is taken every day and progestogen for 12 to 14 days. At the end of each course of progestogen there is some bleeding as the body “withdraws” from the hormone and the womb lining (endometrium) is shed. Progestogen regulates bleeding and protects the endometrium from harmful pre-cancerous changes.
• Oestrogen-alone HRT is normally prescribed to women who have had their womb removed (hysterectomy). The benefits of all HRTs are derived from oestrogen; progestogen is only necessary to protect the womb lining.
• Continuous Combined Therapy (CCT) involves combinations of an oestrogen and progestogen prescribed continuously to achieve period-free HRT. Usually, women start on cyclical HRT and change to CCT later.
• Tibolone is a synthetic form of period-free HRT which may have similar benefits to CCT. It is taken continuously in tablet form.

Bioidentical HRT

Bioidentical hormones are preparations of hormones which are identical to the hormones produced by the human ovary, adrenal gland and thyroid glands. They are compounded by “specialist pharmacies” and are available as lozengers, creams and vaginal preparations. They are usually compounded with some Progesterone, DHEA and Testosterone. However, they are not regulated and the doses and purity can vary, be inaccurate and be inconsisitent. The efficacy and safety of Bioidentical HRT is unknown. Some conventional HRT preparations are actually bioidentical including Micronized progesterone which is the natural progesterone products by the Ovary and 17-beta Oestradiol which is the natural human Oestrogen.