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Osteoporosis in postmenopausal women: key aspects of prevention and treatment

Angela Sheu, Jacqueline Center
OPEN ACCESS

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Abstract

Osteoporosis is a common and costly condition that has significant morbidity and mortality after a fracture. Despite robust evidence that treatment reduces the risk of future fractures, many people in Australia are not adequately treated. This review covers our current understanding of prevention and treatment of osteoporosis in postmenopausal women in Australia.

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Key Points

  • All patients with osteoporosis should be reviewed with regard to modifiable factors and use of nonpharmacological therapies.
  • Calcium supplementation is recommended for patients with low dietary calcium intake after discussion of the potential risks.
  • Vitamin D supplementation is recommended to maintain vitamin D sufficiency.
  • Antiresorptive therapies (bisphosphonates and denosumab) are highly effective in reducing vertebral, hip and nonvertebral fractures and have a safe adverse effect profile.
  • Hormone-related therapies are a good alternative for women in the perimenopausal or early postmenopausal stages.
  • Teriparatide is the only anabolic therapy currently available in Australia.

    Picture credit: © Antonia Reeve/SPL

O

steoporosis is a systemic skeletal disorder characterised by reduction in bone mass and disruption of bone microarchitecture, leading to decreased bone strength and increased susceptibility to fragility fractures. Osteo­porosis is a significant health issue, with 4.7 million people in Australia (66%) over 50 years of age affected by poor bone health. In 2012, the total cost of osteoporosis and osteopenia was $2.75 billion.1

The prevalence of osteoporosis and its associated costs are predicted to increase every year. Prevalence data are likely to provide a significant underestimate because the diagnosis is often missed until a fracture occurs. Furthermore, diagnostic investigations (primarily bone mineral density [BMD] testing) are underutilised even after a patient has a minimal trauma fracture. As a result, people with undiagnosed osteoporosis are at high risk of a fracture and its associated morbidity, mortality and financial costs. Screening and confirmatory dual-energy x-ray absorptiometry (DXA) should be used in people at risk, and after a fracture. Inadequate treatment of a first fracture constitutes a critical missed opportunity to prevent subsequent fractures.

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As the population ages, the number of fractures in older adults will increase. These fracture rates can be reduced with an increase in diagnosis and treatment of osteoporosis and increased awareness of falls prevention.2,3 Thus, early identification and treatment of patients at risk of osteoporosis and those with a fragility fracture may reduce the health burden and associated costs.

Nonpharmacological prevention and treatment options

Exercise and other modifiable lifestyle factors

There is evidence that regular moderate-intensity exercise in children increases bone mineral content in weight-loading sites (femur, tibia and fibula) and may delay the onset of osteoporosis in later life.4,5 In adults, a meta-analysis evaluating the effect of resistance exercise found an increase in the BMD at the femoral neck and lumbar spine only when resistance training was combined with high-impact or weight-bearing exercise (no significant effect was seen with resistance training alone).6 Because fractures result from falls, exercise and balance programs have been evaluated for reducing fractures. A multimodal exercise program targeting prevention of functional decline through resistance training, education and behavioural change showed improvements in lumbar spine and femoral neck BMD, muscle strength and balance, but no change in falls rate.7 There has been one randomised controlled trial with fracture as the primary outcome and three meta-analyses that suggest exercise reduces fractures if it includes resistance training or multimodal robust exercise regimens.8-10 However, the effects of exercise are modest and site-specific. Exercises should be tailored to individuals and initiated under supervision. Exercises such as yoga and tai chi may improve balance and muscle tone and may reduce falls. Patients with low vertebral BMD or previous vertebral fractures should avoid forward spine flexion, and any targeted exercises should begin at low intensity with a gradual stepwise increase in intensity, repetitions and movement patterns to allow for dispersed load distribution.11

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Other lifestyle factors that should be addressed include cigarette smoking (which is associated with low BMD), excessive alcohol consumption (which contributes to low BMD and increases falls and fracture risk) and assessment of balance, home environment and other medications (such as sedatives, antihypertensive medications and corticosteroids), all of which can contribute to excess falls and fractures.

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Dr Sheu is an Endocrinology Advanced Trainee at St Vincent’s Hospital, Sydney; Professor Center is a Senior Staff Specialist at St Vincent’s Hospital, Sydney, and Head of Epidemiology and Clinical Studies in the Bone Biology Division at the Garvan Institute of Medical Research, Sydney, NSW.