The role of the gynecologist in screening & prevention of Osteoporosis

1. The role of the gynecologist in
screening & prevention of
Osteoporosis
Aboubakr Elnashar
Benha University Hospital
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2. Outline
•Introduction
•Screening
•Prevention
•Role of gynecologist
•Conclusion
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3. Introduction
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4. Women health Clinic
•Screening for breast cancer
•Screening for cervical cancer
•Pre conceptional counseling
•Contraception
•Sexual dysfunction
•Menopausal
•Screening & prevention of osteoporosisABOUBAKR ELNASHAR

5. •Consequences of Hip Fractures
5–20%: mortality within 1 y
20%: severely impaired mobility
50%: do not regain previous mobility
• In women >50y, the lifetime risk of
(NICE,2008)
Vertebral fracture is 1/3
Hip fracture is 1/5
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6. Osteoporosis
Silent disease {by the time any symptoms (pain &
fractures) became apparent, the disease is already far
advanced}.
The nightmares of post-menopause
Progressive, systemic disorder characterized by:
•Low bone mass
•Micro-architectural deterioration of bone tissue
•Increase in bone fragility & susceptibility to fracture
(NICE, 2008)
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7. Normal bone Osteoporosis
Microarchitectural
deterioration
Low bone density
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8. Sites:
Any
Common
•Lumbar & thoracic spine
•Proximal femur.
•Distal radius
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9. Bone mass
•35% of cortical & 50% of cancellous bone mass are
lost over a lifetime
•The peak bone mass attained is a major
determinant of subsequent bone mass& fracture
risk in later life (Bonjour et al,1997).
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10. •Determinants of peak bone mass
Genetic factors:
At least half of bone strength is attributable to genetic factors;
Genetic risk factors: age, family history, female sex, low wt, small
frame, and white or Asian race.
Gonadal status
Nutritional status
Physical activity
Modifiable factors may contribute almost equally
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11. Screening
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12. The US Preventive Services Task Force
American Association of Clinical Endocrinologists,
The North American Menopause Society,
The American College of Obstetricians and Gynecologists,
•Indications
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16. Major
• Age ≥ 65 yr
• Vertebral compression fracture
• Fragility fracture after age 40 yr
• Family history of osteoporotic
fracture
• Systemic glucocorticoid therapy ≥ 3
mo
• Malabsorption syndrome
• Primary hyperparathyroidism
• Propensity to fall
• Appearance of osteopenia on
radiograph
• Hypogonadism
•Early menopause (< 45 yr)
Minor
• Rheumatoid arthritis
• History of clinical hyperthyroidism
• Long-term anticonvulsant therapy
• Weight loss > 10% of body wt at
age 25 y
• Weight < 57 kg
• Smoking
• Excess alcohol intake
• Excess caffeine intake
• Low dietary calcium intake
• Long-term heparin therapy
V. 1 major or 2 minor clinical factors
(SOGC Clinical Practice Guideline, 2009)
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17. The FRAX® tool has been developed by WHO to evaluate
fracture risk of patients. It is based on individual patient
models that integrate the risks associated with clinical risk
factors as well as bone mineral density (BMD) at the femoral
neck.
The FRAX® models have been developed from studying
population-based cohorts from Europe, North America, Asia
and Australia. In their most sophisticated form, the FRAX®
tool is computer-driven and is available on this site. Several
simplified paper versions, based on the number of risk factors
are also available, and can be downloaded for office use.
The FRAX® algorithms give the 10-year probability of
fracture. The output is a 10-year probability of hip fracture
and the 10-year probability of a major osteoporotic fracture
(clinical spine, forearm, hip or shoulder fracture).
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18. Age
Sex
Weight
Height
Previous fracture
Parent fractured hip
Current smoking
Glucocorticoids
Rheumatoid arthritis
Secondary osteoporosis
Alcohol 3 or more units/day
Bone mineral density
(BMD)
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19. Methods
I. DEXA (Dual Energy X ray Absorbometry)
The best predictor of hip fracture and an equivalent predictor of other fractures.
The total hip, femoral neck, and posterior-anterior lumbar spine should be measured, using the
lowest of the three BMD scores.
The technical standard (ACOG, 2004)
•Measures important sites of osteoporotic fractures.
•High precision& accuracy.
•Relatively inexpensive
•Modest radiation exposure .
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20. DEXA: 2 x-ray beams of different energy levels
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21. DEXA
1
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22. Interpreting DEXA Results
T scores (comparison with the young adult mean):
relates to absolute fracture risk
Z scores (comparison with reference values of the
same age): related to the individual’s relative risk
for their age.
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23. •T score ≥ -1
•T score -1 to -2.5
•T score < -2.5
Normal
Osteopenia
Osteoporosis
WHO Classification of BMD
using DEXA
•T score < -2.5
+ H. of fractureSevere Osteoporosis
T score represents the number of SD a patient is above or below
the mean BMD of a young adult. ABOUBAKR ELNASHAR

24. Australian Family Physician, 2004
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25. II. Tests other than DEXA (peripheral bone
densitometry devices
(ACOG guideline, 2004)
1. Quantitative US (QUS) .
2. Single-energy x-ray absorptiometry.
3. Peripheral DEXA
4. Peripheral quantitative computed tomography
less expensive
low radiation exposure
low precision& accuracy.
Measure peripheral bone only.
Cannot replace DEXA scans .
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26. Q US
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27. III. Biochemical markers.
Reflect bone turnover
Have potential use in diagnosing&
monitoring therapy of osteoporosis.
Not recommended at this time.
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28. Prevention
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29. • Types of prevention of osteoporosis.
1. Primary:
Aims at reaching at adolescent age a peak bone
mass as high as possible.
Should begin in childhood& continue throughout the
life span to maximize bone mass.
E.g. sufficient calcium intake, omit risk factors
2. Secondary:
Aims at reducing bone loss peri & postmenopausal
E.g. estrogens/gestagens, bisphosphonates
&SERMs.
3. Tertiary:
With manifest osteoporosis aims at preventing
fractures.
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30. Strategies for prevention of osteoporosis:
1. High risk strategy:
To identify women at risk & offer intervention
2. Global strategy:
Population based, where the aim is to modify the
risk factors in the general community
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31. 5 steps for maximizing peak bone mass
(National osteoporosis foundation)
Most important for women who haven't reached their
maximum peak bone mass, which usually occurs
around the age of 30.
Step 1: Daily recommended amounts of ca & vitamin
D
Step 2: Regular wt-bearing exercises
Step 3: Avoid smoking& excessive alcohol intake
Step 4: Risk factor assessment of developing
osteoporosis.
To institute strategies to maximize peak bone mass
and minimize loss before it is too late to prevent the
disease.
Step 5: When indicated, BMD test to see if
medication is needed ABOUBAKR ELNASHAR

32. 5 steps to minimizing bone loss especially after
menopause
(National osteoporosis foundation)
Step 1: Balanced diet
Regular exercise program
Adequate intake of calcium in diet,
Regular sunlight exposure
Step 2: Stop smoking and reduce alcohol consumption
Step 3: Risk factor assessment & screening test
Step 4: If required, medication for osteoporosis
prevention
Step 5: Avoid certain medications
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33. ABOUBAKR ELNASHAR

34. I. Improvement of nutritional intake
1. Ca
Adequate consumption of calcium is essential for bone health.
Calcium balance also can be adversely affected by dietary habits, including high intake of protein, phosphorus,
and sodium, although these effects appear to be less important when dietary calcium is sufficient.
The recommended calcium intake for postmenopausal women (1200–1500
mg/day) can be met with food sources, but supplements should be
added if needed.
Most postmenopausal women in the USA consume only about 600 mg/d.
High-calcium foods include milk (290–300 mg/cup), sardines in oil, with bones (370 mg/3 oz), yogurt (300–500 mg depending on container size),
cheese (165–270 mg/slice), canned salmon, with bones (170–210 mg/3 oz), broccoli (160–180 mg/cup), and tofu (144–155 mg/4 oz).
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35. 2. Vitamin D
Essential for intestinal absorption of calcium.
The recommended intake for women is
400 IU/d for ages 51 to 70,
600 IU/d over age 70, and
800 IU/day for all high-risk women
(homebound, institutionalized, on chronic glucocorticoids, or who live in northern latitudes and
therefore have limited exposure to sunlight)
Sources of vitamin D include sunlight, vitamin D–fortified foods, fish oils, and supplements.
Multivitamins typically contain 400 IU of vitamin D.
Adequate calcium and vitamin D supplementation is key to ensure prevention of progressive bone
loss.
Calcium and vitamin D alone are insufficient to prevent fracture in
those with osteoporosis.
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36. 3. Phytoestrogens
Studies do not support the use of soy foods
to prevent osteoporosis.
A well-designed trial in postmenopausal women found that ipriflavone, a synthetic phytoestrogen, did
not decrease bone loss. Furthermore, use was associated with subclinical lymphocytopenia.
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37. II. Regular exercise
•In children& adolescents:
Wt-bearing physical activity e.g.walking or running contributes to
higher peak bone mass.
•In postmenopausal:
weight-bearing exercise produces small increases in bone
density at the hip and improvement in balance& strength.
Exercise in postmenopausal:
resistance training {improve muscle mass, strength and balance}
balance training which should be performed three times/w
•Women with established osteoporosis:
Activities that place an anterior load on the vertebral bodies e.g.
forward flexion exercises: increased incidence of new vertebral
deformities, and patients should be advised to avoid them.
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38. III. Avoidance of adverse health habits
1. Current smoking, compared with never smoking,
doubles the risk of hip fracture.
2. Consumption of more than 1 alcoholic drink/day or
more than 7/week is associated with osteoporosis
and fracture, while moderate consumption of 1 drink/day or less is associated with decreased
risk.
3. Excessive caffeine intake is also associated with
increased osteoporosis risk and should be avoided.
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39. IV. Medication for osteoporosis prevention
•Indications
T-scores below -2 with no other risk factors
T-scores below -1.5 (but not below -2) with one or more major risk factors
A previous fracture of the hip or vertebral bones in the spine
•FDA has approved
1. Bisphosphonates: most commonly prescribed medication for
preventing osteoporosis in those at high risk.
Bisphosphonates are available in daily, weekly, or once-a-month
tablets
2. HRT: Premarin
3. SERM: Evista
Hormone therapy & raloxafene :
a. other menopausal symptoms such as hot flashes
b. side effects e.g. nausea, from oral bisphosphonates.
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40. V. Avoid certain medications
in those with a high risk of developing osteoporosis
1. Corticosteroids,
2. Heparin
3. Vitamin A
4. Certain antiepileptics: phenytoin [dilantin],
carbamazepine [Tegretol], primidone [Mysoline],
phenobarbital [Nembutal], and valproate [Depakene]
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41. VI. Fall reduction
•Falls are the direct cause of more than 90% of osteoporotic hip
fractures,and the tendency to fall increases with age.
•Some studies have shown that, for women over age 70, the
most important predictors of hip fractures are fall-related factors
such as poor cognitive function, slow gait and otherwise
impaired mobility, poor vision, drugs that impair alertness or
balance, and history of falls.
In women over 75, age and slow gait are equal to low BMD of
the femoral neck as predictors of hip fracture.Unfortunately,
labeling women as osteopenic or osteoporotic can cause fear of
falling and lack of activity, leading to further acceleration of bone
loss.
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42. 1. Medications that interfere with balance or alertness should be
avoided if possible.
2. Environmental hazards such as loose rugs and uneven or
slippery surfaces are also well-recognized modifiable risks for
fallsthat should be eliminated.
3. Hip protectors effectively reduce fractures in the frail elderly
and can boost confidence for beneficial increases in physical
activity levels, but they are often poorly accepted by patients.
4. Other options include referral for gait training, home visits by a
physician or nurse to identify problems in the home that increase
the risk of falls, or providing information on home modification
(such as installing bathtub rails, removing throw rugs, etc.).
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43. Role of Gynecologist
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44. •Women consult the gynecologist
early in their reproductive period,
during pregnancy,
lactation,
premenopausal &
postmenopausal periods for different reasons.
These consultations are precious opportunities for
prevention of osteoporosis.
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45. •The gynecologist prescribes many drugs & manage
different conditions that might be related to or affect the
risk of osteoporosis.
•The gynecologist should be familiar with:
Risk factors
Early detection & prevention of osteoporosis.
•Prevention efforts should be a routine part of the WHC.
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46. I- At adolescent & adult age
A. To achieve a peak bone mass in susceptible group.
•Late menarche
•Menstrual interruptions/irregularities
•Pregnancy
•Lactation
B. To reduce bone loss secondary to drugs:
•Gn Rha.
•Dopamine Agonist
•Glucocortocoied
•Depo-provera??
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47. Adolescent Girls
Disordered eating,amenorrhea, Osteoporosis
Turner Syndrome
90% had osteopenia or osteoporosis
Length of estrogen treatment& BMI showed a positive
association with BMD.
GNRHa for endometriosis:
Add-back’ (oestrogen + progestagen) therapy protects
against BMD loss at the lumbar spine during treatment
and for up to 6 and 12 months after treatment,
respectively (ESHRE Guideline 2005 & RCOG 2006 Grade A)
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48. II- At peri-menopause
To prevent osteoporosis in high risk group
1-Screening
2-Management
III-At Late post-menopause
To prevent age related osteoporosis (>65y)
Usually it is an orthopedic role
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49. Conclusion
1. Because of the economic & social burdens,
comprehensive prevention programs are
needed.
2. The role of the gynecologist is important in all
types & different strategies of prevention of
osteoporosis.
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50. ABOUBAKR ELNASHAR